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Copyright IMS.
BY
ISABKL HAMPTON ROBB.
DEDICATED
TO MY PUPILS
OF THE
ILLINOIS TRAINING SCHOOL FOR NURSES
CHICAGO AND OF
THE JOHNS HOPKINS HOSPITAL TRAINING SCHO.OL
BALTIMORE
7SU9
Prefatory Note to Third Edition.
T N preparing the third edition the entire material has *- been gone over carefully and the book enlarged fifty-three pages. The arrangement has been altered somewhat. Chapters II and III having been combined to form Chapter II, and Chapters VIII and IX to form Chapter IV. Two new chapters have been added, and elsewhere new material has been substituted for old. The first chapter has been entirely changed. Instead of the schedule for a two years' course a suggestive outline for the division of work over the three year* of instruction, which is made to include a six months' preliminary course, ha> been given. This preliminary course is so arranged that during this period a definite ■mottnl of practical and theoretical work is covered. A class of probationers is made up for the spring and autumn, each class being divided into five sections, (A, B, C, of group I. and D and E of group II) with .in equal number of pupils in each section. At the end of a certain number of weeks the sections exchange work, until the entire course, lasting over a period of *ix months, is covered. Classes, lectures and demon- strations occupy the afternoon hours. It is not In- tended that the probationer shall do any actual nursing but during the morning hours from 7 to 11, and again from 5 to 7 in tho afternoon she is required to perform certain domestic duties In the strdi nudes 1 1 1 « - obser- vation and criticism of regular instructors, who must he graduate nurses of experience. By thin method the
8 PREFAC&
probationers will become practically familiar with all the details of the methods employed in each depart- ment, and will be taught their relation to the care of the patient before they are called upon to undertake actual nursing duties. This arrangement at the same time will relieve the nurses of much of the domestic vide of their work and thus enable them to devote more time to the actual nursing, with the result that the patients will receive better care.
Prefatory Noie to Second Edition.
IN preparing the second edition very little lias been changed, hut new matter lias been added to bring tin- Look up to the latest methods. A suggestive chap- ter has been added on the division of work over three years of instruction, and courses of lectures have been mapped i 'in tO COVei thit I : t : n ■ . Some rif.v GgUKl have been added, of which the majority illustrate the appliances employed in surgical work, which have been tested and found of practical use.
My thanks arc due to Dr. J. Whitridgc Williams for his criticism! and suggestions on the obstetrical chapter; and to Dr. Booker, of Baltimore, and Dr. ard dishing, of Cleveland, for reviewing the chap- ter on children ; also to many of my friends among superintendents of training schools for suggestions and material. The form of marking the pupil nurses' standing was kindly supplied me by the Superintend- ent of the Lakeside Hospital Training School.
CONTENTS
CHAPTER I.
Suggestive Outline for the Three Years' Course — Ex- aminations— The Preliminary Course — Classes, Lectures, etc., for (a) First Year, (Second Half)— (b) Second Year Students— (c) Third Year Stu- dents— Reference Library — Form of Report 17
CHAPTER II.
Economics of the Hospital Ward, Free and Private — Construction — Furnishings — Hygienic Arrange- ments— Ward Supplies — Ward Work — Daily Sani- tary Care of the Ward, of the Beds and Blankets — Care of the Ward Utensils — Personnel 42
CHAPTER III.
Hygiene of the Sick-Room and Ward — Ventilation — Temperature — Light — Disposal of Excreta, Soiled Dressings and Soiled Linen 59
CHAPTER IV.
Bacteriological Notes — Sterilization and Disinfection — Disinfectant Solutions — The Metric System — The Preparation of Solutions — Disinfection of Cloth- ing, Rooms, Furniture, Wards, Excreta, and Ves- sels— Isolation and Quarantine 75
CHAPTER V.
Beds — Bed-Making for Bed Patients; for Convales- cents— To Prepare a Bed for an Operation Pa- tient—Fracture Beds — Mechanical Appliances for the Relief of Bed Patients — Lifting and Moving.. 101
11
13
CONTENTS
CHAPTER VI.
Care of New Patient— Treatment— What to Observe
— Reporting to the PhyaiciaO' Care of the Bed
ients — Frequency of Bathing — Care of the
Teeth and Mnutli— The Prevention and Treatment
of Bed-sores— Care of Convalescents 120
CHAPTER VII.
Baths (Classification — Temperature — Baths for Clean- bur Tub-Hatlis— Fool-Baths — Baths U Thera- peutic Agents — Mustard Baths — Simple Hot Baths — Hot-Air, Steam, or Vapor Baths— Salt-Water Bath— Bran and Starch Baths— Sponge-Baths and Tub- Baths in Typhoid Fever— The Cold Pack —The Continuous Bath 138
CHAPTER VIII.
Enemata— Kinds— Methods of Preparation — Frequency and 1 \ilministration— Care of Appliances
—Douches— Catheterization— Lavage of the Bladder. 156
CHAPTER IX
Temperature — Pulse — Respiration — Care of the Ther- mometer—Charting and Recording Notes 171
CHAPTER X.
External Applications (General and Local)— Dry Heat — Hot-Water Ban and Cans— Hot Bottles, Manuel-. Salt-Bags — Moist Heat — Fomentations — Poultices— Moist-Air Tent — Cold Applications- Ice— Cold Water— Lotions 19a
CHAPTER XI
Counter-Irritant' — Mustard Poultices and Plaster*— Turpentine — Iodine — Cupping — Cantharides — The Cautery aos
CHAPTER XII
Medicines — Method of Administration — Dosage —
Weights and \l.-.. Itdic I I icdi-
cine Lists 218
CONTENTS 13
CHAPTER XIII. Diet in Disease 238
CHAPTER XIV. How to Observe, Report and Record Symptoms 253
CHAPTER XV. The Urine 270
CHAPTER XVI. Nursing in General Medical Diseases 280
CHAPTER XVII.
Medical Emergencies — Artificial Respiration — Drown- ing — Poisons — Medical Appliances — Medical Rounds 303
CHAPTER XVIII.
Surgical Nursing — Aseptic and Antiseptic Surgery — The Healing of Wounds — Inflammation — Compli- cations— Surgical Dressings — Preparation of Pa- tients for Operations (Capital and Minor) — Care of Patients After Operation — Nursing in Surgical Diseases 317
CHAPTER XIX.
Bandages — Surgical Emergencies — Shock — Fractures — Surgical Appliances — Dislocations — Sprains Contusions — Burns and Scalds — Frost-Bite — For- eign Bodies in the Eyes, Nose, Ears, and Larynx. 340
CHAPTER XX. Hemorrhages 366
CHAPTER XXI.
Surgical Operating-Rooms — Nurse's Technique — How
to Prepare for Operations in Private Houses 380
•4
CONTEXTS
CHAPTER XXII.
'iynjrcology— General and Special Preparation of Pa- tient* for Examinations and Operations — Posin — Instrument* and Dressings — Care After an Ab- dominal Section and Minor Operations — Gynae- cological Terms and Definitions 398
CHAPTER XXIII. The Administration of Anesthetics
417
CHAPTER XXIV.
Infectious Diseases— Fever — Typhoid Fever— Malarial Fever — Scarlet Fever — Dysentery — Asiatic Chol- era— Small-Pox — Diphtheria — Pulmonary Tuber- culosis 427
CHAPTER XXV.
The Nursing of Children — Convalescent Children- Thrush — Cholera Infantum -Convulsions — Infan- tile Paralysis — Chorea — Rickets — Croup— Eczema — The Infectious Diseases of Childhood 450
CHAPTER XXVI.
Obstetrics — Pregnancy — Symptoms and Physical Signs —Development of the Foetus — Abortion — Miscar- riage— Premature Labor— Care of the Patient Be- fore, During, and After Labor — Care of the Breasts — Care of the Child — The Puerperal State 483
CHAPTER XXVII.
Disorders of the Special Senses — Nursing in Diseases of the Eye, Throat. Nose, and Ear 513
CHAPTER XXVIII.
Nursing in Nervous Diseases and Insanity— The Rest
Cure — Massage— -Electricity 52J
ILLUSTRATIONS.
PLATES.
PLATES.
I.— Nurses' Toilet-baskets tob Patients Frontispiece
II.— Surgical Operation Bed Face Page 108
III.— Pneumonia Chart " " 190
IV.— Typhoid Fever Chart " " 190
V.-Malaria Chart " " 190
VI.— Bed-side Record '* *' 191
no. page.
1.— Crane for Assisting the Patient to Move Himself
in Bed Ill
2.— Heel Cushion 114
3.— Rubber Protective Pad 118
4.— Form por Listing the Clothes op a Patient 124
5.— Stupe- wringer 199
6.— Paquelin Cautery .' 214
7.— Heel-rest 343
8.— Buck's Extension Apparatus 355
9.— The Bradford Frame 356
10.— Modified Scultetus Bandage 405
NURSING:
ITS PRINCIPLES AND PRACTICE
CHAPTER I.
Suggestive Outline n« the Thru Yiabb' C<u-rse — Examinations.— i in I'la.i.nii:. wsfc— Classes
Lectures, etc., for (a) First Year, (Secoxo Half) — (6) Second Year Sti-uknts.— (e) I'mm Vi .ar Sti-dents. — Ruysencc Library.— Form or Rei-ori.
A general outline of the plan that aught lie followed daring a three years' course of instruction is g here. This may be of practical use as an aid to in- liog students, and at the same time may serve to impress upon them the fact that the work can not be done haphazard, that System and method must prevail throughout, and be cultivated OS part of ilnir training. A detailed account of the whole curriculum will be found elsewhere.
a Suggestive Outline roi .\ Tiikf.k Years' Course of Instruction.
The course of instruction is to be graded and ex- tend over three years, including the time of probation. Practical work in the ward, demonstrations at the bed- side, in the class-room and the laboratory, should be preceded and supplemented by a regular course of lec-
2 V>
iS
.VUKSING
tures and recitations. As far as possible the work of any given year should be a necessary preparation for * that of the succeeding one. Lectures and classes should extend throughout the entire first year, but in the second and third years they should be limited to the regular teaching months, from October until May. The pupils arc divided into three classes, belonging to the first, second and third year respectively. During the three years' graded instruction, practical and theo- retical, is given in the following subjects: bacterio- logy, hygiene, household and nursing economics in- cluding dietetics, anatomy, physiology, materia medica, the principles of nursing and their practical application to the, care of medical, surgical, gynaecological and obstetrical patients, as well as in mental and infectious diseases. Special attention is also given to the subjects of surgical technique, massage and the ethics of nurs- ing.
FIRST YEAS.
The first six months of the first year are devoted to a preliminary course for probationers. This course b given to the student before she is allowed to begin her practical nursing in the wards, and embraces the elements of anatomy, physiology, hygiene, bacterio- logy, household economics including invalid dietary, materia medio, the dementi of nursing, and hospital ethics and etiquette for probationers. These subjects arc taught by lectures, demonstrations, recitations and by praii:
During the second half of the year classes in the principles of nursing arc held, the pupil is taught the practical care, in the wards, of the ordinary medical, surgical and gyn-xcological patients, and towards the
OUTUSE OF WORK 1 9
end she can undertake her first term of night duty. During these months she attends lectures dealing with the various branches of medicine and surgery, the changes that take place in the various systems of the body when invaded by disease, the signs by which they may be recognized, together with the duties of a nurse in regard to them, and the ethics of nursing for first-year nurses.
Lectures. — A systematic course of didactic lectures in connection with the above subjects, is given by specialists in their various branches. Notes upon each lecture are to be taken and written up in full by the student later.
Second Year.
Practical Work. — A service in the dispensary and in the general surgical operating-rooms; the care of the patient before and after operation ; special nursing in the public and private wards; and a term of night duty.
Class-work. — Testing of urine; nursing in medical and surgical diseases ; surgical technique ; anaesthesia ; the care of children ; nursing in infectious diseases, and the ethics of nursing. Lectures on the above subjects in connection with the class-work are given by physi- cians.
Third Year
Practical Work. — A service in the obstetrical ward, and the care of the nervous and insane. Class-work and lectures upon obstetrics, massage, nursing of the nervous and insane and upon special subjects — nursing in diseases of the eye. ear, throat and skin — and on scientific appliances, as electrical apparatus, the Roent- gen Rays, the Finsen light, etc.
20
NUKSI.S'C
During the lust six months Mmlcnts who wish to prepare for hospital positions arc expected to act as head-nurses in the wards or as night head-nurses, as supervising nurses, u assistants in the snperintMi.l .iii> office, and t" hold classes under the observation and criticism of the superintendent. Students who de- sire to qualify more especially for private practice should be given special advantages in whatever branches they may fee! deficient.
I ■ m i N m IONS.
Unless the probationer holds ■ high-school certificate or its equivalent, an examination in Knglish branches of study should precede her acceptation as a pupil. At the end of the preliminary course the probationer should be examined in the subjects taught In that course, namely, bacteriology, hygiene, household econ- omic*, dietetics, anatomy and physiology, the ektnentt of nursing and materia medica. At the end of the first year the subject.-, for examination are: (i) The principles of nursing; (2) Medical nursing; (3) Surgical nursing. At the end of the second year: (t) The examination of urine: (2) Duties of the operating-room nurse with special reference to surgical i hnique; (3) Gynaecological nursing: (4) The care
Of sick children: (5) Nursing in infectious dlSX The subjects of the third year examination should in- clude: (1) Nursing in obstetrics; (2) Nursing in nervous diseases and insanity; (3) Special nursing subjects; (4) Private nursing: (5) The ethics of nursing.
|
• OUTLINH Of WOHK 2! |
|
|
TABLE— SHOWING A SCHEME HOR INSTRUCTION |
|
|
EXTENDING OVER THREE YEAHS. |
|
|
Six Months' Preliminary Course of Instruction |
|
|
for Probationers. |
|
|
(Subjects divided into two main groups.) |
|
|
Group I — Household ECONOMICS. |
|
|
A |
The hospital, and the practical care of its wards. |
|
sick-room*, lavatories, bath-rooms. |
|
|
B |
Care of the linen : in the central linen-room ; in |
|
the ward | in the laundry. |
|
|
c |
Dietetics: in the general kitchen; in the diet |
|
IdtchM j in the ward kitchen. |
|
|
Group II— Nursing Economics. |
|
|
A |
Bacteriology. |
|
li |
Practical chemistry; hygiene and ventilation; |
|
methods of heating. |
|
|
C |
Anatomy ami physiology. |
|
Classes and demonstrations in practical nursing. |
|
|
D |
Materia medii-a. |
|
Pharmacy, |
|
|
B |
TJie surgical supply room. |
|
F |
Ethics and hospital etiquette. |
|
General Plan of Practical Work. |
|
|
i |
The six months to be divided as follows |
|
Group I— Household Economics. |
|
|
-f |
Five weeks. |
|
B |
Five weeks. |
|
c |
Six weeks. |
12
AY .VN/.W.
Group II— Nurkinc. Economics. D Five weeks. E Five weeks.
The practical work to be done in the morning under the instructors. Classes and demonstrations in the afternoons to precede the practical morning work.
Daily Prtulital Morning Work.
Group I
A (i) The wards and sick-rooms; (2) bath-rooms
and lavatories. la Proper airing of room, beds and bedding:
Daily general care of room or ward : windows,
window shades, floors, furniture, rugs. b Cleaning of bed frames.
e The making of beds for convalescent patients. d Daily dusting and floor brushing; care of fire and
fire-place ; registers ; flowers and plants; daily care
of the sun-room ; of the patients' library ; method
of preparing room for weekly cleaning ; dusting
down walls ; cleaning windows and brasses ;
sweeping floors ; cleaning rugs and supervision of
maids' work. 2 Bath-rooms :
a Care of walls, floors, tubs, fittings. b Lavatories :
Care of stationary basins, slop- hoppers, refuse cans,
bed-pans, sputum cups urine glasses, bed rubbers,
specimen utensils, etc. t Closets :
Care in the disinfection of closets and ventilation ;
cleanliness and order ; daily care of du«t-cloths ;
cleaning vessels and housemaid's closets.
OUTLINE OF WORK 23
Daily Afternoon Class- Work and Demonstrations. Guoui' I— A — Household Economics.
The hospital— location and surroundings ; its build
ings ; general plan ; methods of heating. The sick-room— location, size, light, ventilation. Construction — Composition of walls: wood, plaster,
cement, tiles and marble. Furnishings: paint,
paper, enamelling, hard cements. Floors — Materials used : woods, cement, cork, tiles,
marble. Finishings : oils, shellac, paint.
Furnishings :
Bedsteads — Materials : iron, brass, wood ; the frame : weight, height, width ; durability ; sim- plicity ; springs ; place in room.
Mattresses, pillows, and materials for making bed: kinds, quality, weight.
Bed-linen : kind, amount necessary.
Chairs : different kinds, and use.
Floor coverings : rugs, linoleum, matting, carpet- ing, cork, rubber.
Tables, washstands, bureaus, wardrobes, lounges, screens, blinds, curtains, china.
Ornaments : flowers, plants, pictures.
Care of sick-room : general and special cleaning of walls, floors, window.%. furnishings and ornaments, bath-rooms, lavatories, and closets ; materials employed.
Relative cost of sick-room : its walls, floors, fur- ni •■lungs, bed-linen, and cleaning materials.
Personnel— The physicians, nurses, orderlies. maids, and the etiquette in relation to each.
*4
AUfiSl.XC
Daily Afternoon Classes and Demonstrations. B — Household ECONOMICS.
The central linen-room: General plan and sub- divisions.
List of materials kept in stock for general use in the wards ; amount and cost ; method of buying linens and other materials; method of sorting and ar- ranging on shelves ; method of counting, and of keeping stock room 1 netho<l of distributing.
Standard linen-list for a public ward ; standard linen list for the private ward; the ward linen- book ; the system of exchange ; mending ; the dis- infection of linen ; removal of stains ; the econom- ical use of linen in the wards ; the systematic changing of soiled for fresh linen in the wards.
Blankets : kind, quality, weight : cleansing and sterilizing; frequency of changing blankets in the ward ; removal of stains ; the care of ward linen- room ; cleanliness, order and ventilation.
The laundry— General plan and equipment ; matc- ii.il> used in the laundry and then cost ; method of counting soiled ward linen in laundry ; method of sorting for mending and counting fresh ward linen; distribution of fresh linen to the wards; the sewing room.
Daily Practical Aforning Work. (ieneral care of ward linen-room — counting, sort- ing, folding and placing fresh linen on shelves ; counting and disinfecting soiled ward linen in the laundry disinfecting room ; counting ami sorting fresh linen in the laundry; the keeping of the ward [jnen supply book ; the listing and care of patient*' clothes.
oar use of wokk
»5
C— I r, QHOHica
Daily Afternoon Class - Work and Demonstrations
The general kitchen : plan ami Kcncral equipment: store-rooms, cold storage room; general diet lists; methods <>f f I distribution.
The ward kitchen : furnishings; daily care; week- ly care; the counting of silver and china; the serving of meals and special diets ; the prevention ol water-bugs; kitchen linen.
B invalid diet kitchen: course of talks and deiii"ii>tr:itions on foods and food principle*; the physiology of the alimentary secretions; the assimilation of food.
Daily Practical Morning Work
General care of the ward kitchen and refrigerator; weekly care of the ward kin lien; weekly counting of the silver and china; care of the sinks and dish-towels; the ward kitchen supply hook; assisting in the serving of ward patients' meals.
Prep of foods in the diet kitchen; the prepa-
ration and serving of trays; the serving of special diets to patients.
OUTLINE OP COURSE IN DIET KITCHEN
The kitchen location, furnishings, care; stoves: kinds, management, fuels; care of refrigerator, cupboards, silver and china, kitchen towels and linen.
Composition of tin
Foods : production and manufacture, preservation and adulteration, Bacteriology in relation to food. Foods in general : need, uses, condu
16
NURSING
Influencing the amount needed; clarification of food-stuffs, with examples; a balanced diet; the complete digestion of a perfect food, such as bread and butter.
I i'imh iple*:
Water : use, amount needed by an average man, ir»ult of deficiency or total deprivation; test for hard water, ami rrtneily; the effect of hot or cold water in cooking.
I effect on system; principal salts derived i lite*; excess; deprivation; classes.
ProtlM 'I')' so called; need for; classification; lOttNM i characteristics; digestibility.
. ,i (a) Milk: varieties; composition
dwi' and human milk; digestibility; the modi- fication of milk for infants and for children in dis- ease; how to make lime-water and barley-water; m.-thods of modifying milk; the preservation of milk; methods of sterilization; pasteurization; in- fected milk; ptomain poisoning; the predigestion of milk; peptonized; pancrcatized; koumiss; jun- ket; wine-whey.
(b) Milk Products. Principles and mechanism of the cream-separator; cream; evaporated cream; skim milk; condensed milk; its objections as food for infants; buttermilk; whey; cheese; kinds; how made; digestibility; oleomargarine; cottolene ; tests; experiments.
(c) The preparation of foods in which milk is chiefly or wholly used. Diseases in which milk is indi- cated as a food. The Walker-Gordon laboratory.
OUTLINE OF WORK
17
Kggs : composition; test for freshness; how best kept; digestibility; uses; the best forms and prep- aration when indicated in disease; experiments.
Meats: comparative constituents of meats and vegetable*; arguments for and against meat diet; uses and abuses; digestibility; difference between old and young animals; length of time for diges- tion, etc.. for beef, lamb, mutton, veal, pork. poultry. 6lh| oysters.
The different cuts of each and method of preparing for the sick : (1) in solid, and (2) in liquid form. Soups, teas, extracts and jellies. Fish : boning, cooking; the garnishing and serving of meat in its various forms.
Carbohydrates : meaning. Principal carbohy- drates; uses; digestibility; special carbohydrates.
Sugar: Varieties; sources; uses; tests for cane sugar, glucose, etc.; when to be avoided; sacchar- ine and its uses.
Starch and Cereals : formula for starch; experi- ments; digestibility; the cooking of starch.
Cereals : wheat and flour; milling processes; gluten and wheat flour.
Flour: yeast plant and bread; starchy vegetables; chief flour mixtures and preparation.
Vegetables: chief vegetable proteids; digestibility; classification; properties; characteristics; best methods of cooking. I-'ats and oils : why neces- sary ; amount needed. Salads : uses, preparation and serving.
Fruits : composition : classification ; uses and properties ; digestibility ; preparation and serving of the various fruits.
28 MOUSING
6 Stimulants and beverages: tea, coffee, chocolate;
how grown; adulteration; rules for making; effects. Mineral waters : composition, uses, effects. Bev- erages of other kinds : uses and effects. Alcohol : as a food ; as a stimulant ; action upon bodily temperature ; absorption ; elimination ; clinical uses. Wines and malt liquors : composition and uses.
7 Desserts : all kinds of gelatine preparations ; their
nutritive value ; fruit, jellies, and puddings ; ices and creams.
Food in relation to disease; menus for special diseases and method of preparation, as for diabetes. The proper food for infants, children, and con- valescents.
How to set and serve trays; the planning of meals.
Group II — Nursing Economics.
Afternoon Classes, Lectures, Demonstrations, and Laboratory Work.
A — Bacteriology.
History : bacteria ; classification and characteristics ; infection and its sources ; culture media ; cultivation, sterilization and disinfection. The relation of bacteri- ology (i) to the nurse's daily hospital duties; (2) to cleanliness and sanitation; (3) to ward and laundry supplies; (4) to air, water, food; (5) to infectious diseases; (6) to aseptic and antiseptic surgery, surgi- cal fevers, etc. The prevention and limitation of cer- tain diseases.
Microscopical demonstrations and methods of des- troying bacteria.
OUTLINE OF WORK
*9
B— Hygiene, Ventilation, Heating.
Afternoon Classes, Lectures, Demonstrations, and Laboratory Work.
A course in elementary physics and chemistry in rcation to air, ventilation, soil, water, and food, (2) Hygiene in relation to hospitals. (3) Hygiene in relation to the home. (4) Personal hygiene.
Hygiene: air: chemistry of, influence of, amount required; changes it undergoes; causes of im- purities ; detection of impurities ; method of test- ing the quality of air; statistics of cultures from air breathed in the hospital at different hours.
Ventilation: principles, various methods, best methods. Heat: in relation to health; dry and moist; methods of heating (a) institutions; (b) private dwellings; amount of heat required in a sickro im how to maintain > proper temperature;
modes of measuring heat ; the ward thermometer, rriology, ventilation and fresh air.
Home sanitation: the house; site, soil, surround- ings; drainage; lanitan fittings; main waste- water pipe: its care, foreign l>»lics in; kitchen- and pantry-sinks, laundry-tubs, bath-tubs, and slop-hoppers . soil -pipe system ; location of water- closets; dangers, and how detected; garbage and its can-.
Bacteriology in relation to the home.
Watei ; the Chemistry of water in relation to health; characteristics of wholesome water; dangers of impure water ; organic and inorganic constitu- ents to be found in water ; sources of water sup- m iles of supply ; sources of contamination ; method oi purifying; analysis of water.
JO tfV/tS/NG
Bacteriology in relation to water.
Climate: effects of altitude, location and soil on
health. 4 Personal hygiene: food, sleep, bathing, exercise,
recreation, minute care of the body ; clothing for
infants, adults, old age ; protection of the feet ;
bacteriology in relation to the preservation of
health : vaccination.
C— Anatomy and Physiology. Daily Afternoon Classes and Demonstrations.
Embryology: study of cells and tissues: the cell, its properties and {unctions, kinds, propagation, repair and death ; development of the human em- bryo; outline of the human body.
The skeleton : gross, microscopic, and chemical structure; composition of bone, joints, cartilage, and muscle ; names of bones and their functions, nutrition, periosteal covering, divisions, rod number.
Joints: varieties, divisions, motions, structural formation.
Muscles: varieties, functions, structure, origins and insertions ; tendons and fascia:.
V iaoenl anatomy: anatomy and position of viscera; physiological laws governing the functions of the internal viscera, the circulatory, respiratory, and lymphatic systems; the excretory organs: the generative organs ; the nervous system ; organs of special sense, an 1 1 pliy>iological laws governing them; the glandular system; the physiology of the secretions and excretions.
OUTLINE OF WORK
3»
Classes and Demonstrations in Practical Nursing.
Training in note-taking and in written and verbal reports. The general care of the hospital ward or private sick-room, comprising: (a) the location, furnishing, and supplies; (b) sanitary method of caring for the ward ; sweeping, damp-dusting, brushing, and cleaning beds; care and cleaning of bath-rooms, lavatories, water-closets, drain-pipes, basins, and traps ; care of plants and flowers.
Nursing hygiene: ventilation, air; methods of ventilating. Hashing, and warming : the ther- mometer; methods of regulating the temperature; protection of patients from draughts.
Disinfection and disposal of vessels, dust-cloths, brooms, brushes, soiled linen, soiled dressings, excreta, sputa, mouth-sponges, special dishes. The special disinfection of clothing, furniture, wards, or rooms. The use of disinfectant solutions; of deodorizers.
Beds : bed-making for ordinary patients, for con- valescents, for operation patients, for fractures; the changing of linen ; the arrangement of mechanical appliance! for thi n Hi t of bed patients;
lifting and moving; mechanical restraints.
Care of patients: treatment; what to observe and report ; care of the bed patients ; bathing in bed; care Of the teeth, mouth. eyes, hair, nails, and back; prevention and treatment of bed-sores; care of delirious patients, of convalescents; care of the dead.
4 Baths : (or cleanliness; as therapeutic agents.
3*
WVRSING
5 F.nemata: kiml- ; nicihods of preparation; mode of
administration. lavage: of intestines, of stomach, Of bladder; douches; catheterization.
6 Temperature: pulse; respiration; charting: record-
ing notes.
7 External applications (general and local); dry
heat; moist heat.
8 Counter-irritants; the cautery.
9 Medicines: methods of administration; dosage;
weights and measures; tin-'i ysn-m; medi-
cine closets; medicine lists.
10 How to observe, report, and record symptoms.
11 Diet: its importance in disease; its classification
in disease; methods of administering food; stimu- lants; feeding in the acute stages of diseases; in convalescence; the diet in special diseases; the serving of food.
D — Matkkia Mgdica. Afternoon Classes and Demonstrations
1 Medicines: the metric system; tables of weights
and measures. Drill in fractions and percentages; approximate measures; abbreviations; symbols; various vessels used for administering medicines; their care; labels; stoppers; medicine-bottles: kinds, size, shape, color.
2 The medicine-closet : its arrangement, care; preser-
vation of medicines.
3 The order-book : ordering medicines; the medicine-
sheet. Abbreviations for hours of giv ing medicines. Methods of handling, measuring, and administer- ing medicines; precautions to observe; eareofthe hypodermic syringe.
OVTUSE OF WORK
3.1
Organic and inorganic drugs. The classification of drugs. The various preparations of drugs. Drugs acting on the respiratory, circulatory, and excretory systems; their physiological action; in- cidental effects.
Poisons : kinds, doses, symptoms, antidotes, physi- ological symptoms.
Daily Pratttial Morning Work. OUTLINE OP COURSE IN PHARMACY.
Apothecaries' weight and specific gravity ; methods ■ I measuring heat; thermometer.
Sterilization ; filtration.
Distillation and pharmaceutical stills.
Percolation and its application to the manufacture of tinctures. Solutions, simple and chemical; official aqueous solutions and liquors. Simple solutions ; alco- boll< solutions or spirits. GtMOiu rotations; chemical reactions. Ethereal solutions ; collodions. The prcp- antion of antiseptic and disinfectant solutions; uses and precautions. Carbolic acid, bichloride of mercury, boric acid, normal salt solution, Labaraquc's solution, chlorinated soda, lime, listerine.
Outline of process used in making tinctures. Outline of process used in making Bold extract*. Outline of process used in making syrups. Outline of process used in making ointments. Powders, pills, tablets, capsules and medicated wines. Hospital formulae for solutions. The economical use of medicines.
34
Xb'KS/.VG
E — The Central Surgical Supply Room.
Aft. moon lasses, lectures, demonstrations and lab- oratory work,
i. Bacteriology in its relation to the preparation of surgical drcs-ings and solutions.
2. Surgical supplies, kinds, amount, cost.
3. Surgical cleanliness of hands, dressings, uten- sils, management of the sterilizers.
4. The names and care of surgical appliances, the making and covering of |>h:ii-., pads etc., the care of syringes, rubber goods, mending rubber gloves.
5. Bandaging— Materials, uses, preparation, practi- cal application of all kind.-..
6. Surgical suits for surgeons, for nurses: shoes.
7. The etherizing rooms, the dressing rooms.
Practical Morning Work.
1. The preparation of dressings, sponges, iodoform ■x, ligatures, salt solution.
2. The packing of sterilizers, and sterilization of dressings ;'.iul irisii imi. nts for wards, for ojk- rating rooms.
3. The names and care of instruments.
4. The operating rooms — kinds of, general plan of the walls, floor, plumbing, furnishings, linen, care of.
Afternoon Classes. F. Hospital etiquette and ethics for probationers.
i. Etiquette — The relation of the probationer tc other nurses, to physicians, patients, hospital officials, domestics, strangers.
Ethics The probationer, object in entering school history of nursing, (pialifications, personal hygiene.
otrrusE of work
35
First Year (Second half).
I^ttures, demonstrations, bedside-clinics and quizzes. The instruction to be given from the nursing standpoint.
1. Medical Xursing.
Temperature, pulse, respiration — the observation of
gymptoma.
Bacteriology in relation to the nursing of medical diseases. The blood, counting blood. The etiology of, and nursing in. the common diseases of the circulatory system, of the digestive organs, of the respiratory or- gans.
Medical emergencies.
Abdominal symptoms.
Hydrotherapy.
2. Surgical Nursing.
Bacteriology of the common surgical bacteria : their relation to a* pttc and to antiseptic surgery; to aw fevers and traumatic wounds: sources of infection and metltods of invasion; means of prevention
Surgical pathology; inflammation: process of re- pair.
Granulation tissue ; oedema.
Surgical fevers; erysipelas; septicemia; pyaemia; ins; anthrax; fractures and dislocations. COOttl and sprains.
Hemorrhage and shock.
3. Instruction and Practice in Physical Culture.
Second Year.
1. The Urine. — Elementary analysis (practical laboratory instruction to be given to the class in sec- tions).
36
xuies/xc
Diseases of the urinary system— Catheteriza'tk bacteriology in relation to the urinarj organs
2. Surgical Technique.— Surgical operating-rooms. Care of patients before, during and after Opera) Nursing in special surgical and genito-urinary cases. Infant surgery — joint diseases and apparatus. Surgical diseases— tumor*, etc.
3. Gynaecology. — Pelvic anatomy — diseases of the
organs of generation. Preparation of the patient foj
operation and after care. Preparation for major gynaecological operations and afier care.
4. Anesthetics and their administration, with prac- tice.
5. Contagious and Infectious Diseases. — Channels of infection. Prevention and limitation. Immunity from disease. Isolation, disinfection, general treat- ment.
Typhoid fever, malarial fever, tuberculosis, pneu- monia, pleurisy, inftuenzt( meningitis, scarlet fever, measles, smallpox and other exanthemata, diphtheria and allied affections, hydrophobia. Asiatic cholera, amccbic dysentery , glanders and other less common in- fectious diseases.
6. Constitutional Diseases. — Rheumatic affections, arthritis deformans, gout, diabetes, rickets, scurvy. Hodgkin's disease, lymphatism. Simple and exophthal- mic goitre, cretinism, myxocdema.
7. Children. — General care of the young child in health and disease. The diet of the young child in health and disease. Bathing, irrigation of the stom- ach and bowels, etc. ; children's diseases, infantile par- alysis, chorea, croup, eczema, etc.
OWt IM of h-okk
37
8. Massage— A full course of practical talks, demonstrations and practice.
Third Year.
Obstetk
i. Pregnancy : < )rgans of the body concerned in pregnancy and in parturition: t<i) Tin- bony canal, the false -mil true pelvis; (&) The soft parts, uterus, va- gina and pelvic floor.
i. Impregnation: The ovum and its development Ilk' placenta; the 'n-irgement of the uterus; the hy- giene of the pregnant state; diet; care of the bowel-;; care of the breasts, etc.; the vomiting of pregnancy; the > I of pregnancy; quickening, the fecial
heart-sounds, etc. ; table for calculating the probable ilnration of pregnancy — death of the ftXtUS in iilero.
3. Physiology of pregnancy: Condition of the pel- vic organ m; changes in the entire organism; the mature f<ctus: forces bringing about and resisting the birth of the child
4. Natural lal>or: Preliminary preparations for stages of labor ; position of foetus, etc. ; what to do in
oergenc] . the birth of the placenta and its man agemont ; post-partum haemorrhage ; 'accration of the perineum.
5. The puerperal state: Gcanlincss; articles re- quired ; receiving, washing and dressing the child ; the immediate care of the child.
6. The management of the puerperal state: Dan- gers to be avoided ; diet.
3«
AL'KS/XG
Infants.
1. Care of Infants; Condition of the child immedi- :!i!\ after birth — (i) general appearance; (2) bony framework; (3) internal organs; (4) changes in the circulation; (5) establishment of pulmonary respira- tion.
2. Infancy: (1) growth and development of in- fants; (2) physiological peculiarities; (3) tendency to disease; (4) mortality among infants; causes and prevention.
3. Care of IK-.-ihlu Infants- 111 handling; (2) bathing: (3) clothing: (4) sleep. (5) exercise; (6)
the nursery.
4. Infant Feeding: (t) in health; (2) in suk- MM.
5. Infantile Diseases: Ophthalmia neonatorum, thrush, diarrhoea, convulsions, cholera infantum.
Care of i at Nervous and Insane. Nervous diseases, hysteria, neurasthenia ; nervous prostration; effect of the condition "f (he mind upon the body ; nature and causes of insanity ; management
of special forms of Insanity; hysterica] insanity: melancholia and mania, hypochondria, eccentricity.
dementia, delusional insanity, epilepsy and epileptic insanity.
Diseases of tue Skin.
Anatomy and care of the skin.
Nursing in diseases of the skin.
1 'i -1 ■•■■' - oi- j 11 e Eve and Ear.
Anatomy of the eye, care in health and disease.
Care of eyes after operators.
Anatomy of the car; care in health and disease.
REFERENCE LIBRARY
39
Diseases or til Tiikoat and Nose. Disorders affecting; the throat and nose. Treatment and nursing in diseases of the throat and
A good reference library may be made from the fol- lowing works : Gray's Anatomy ', Human Physiology, Foster or Hutchinson; The Human Body, Martin; Bacteriology, Dust and Its Dangers, The Story of the Bacteria, Prudden; The Story of Germ Life, Cohan; Hygiene of Transmissible Diseases. Abbott; Principles and Practice of Medicine, Osier; Materia Medica and Therapeutics, Wood or Hare ; Textbook of General Therapeutics, Hale White ; Diseases of Children, Rotch or Holt; Taylor on Poisons; Practical Examin- ation of Urine. Tyson ; Nursing and the Care of the Nervous and Insane, Mills; Bandaging, Wharton; An American Text Book of Surgery, Keen and White, or Dennis' System; Aseptic Surgery, Robb; Gynecology, Kelly or Penrose; Obstetrical Nursing,]. W. Williams; Puerperal Convalescence and Diseases of the Puerperal Period, Kucher; Massage and the Swedish Movements, Palmer: Drainage and Sewerage of Dwellings, Gerhard; Practical Hygiene. Parks; Hospital Construction. Hil- lings; Dictionary. GouMi f/oUt on Nursing, Florence Nightingale; Guide to District Nursing, Mrs. Dacrc. Craven (Florence Lees) ; Duties of Hospital Sisters, Eva Luckes.
In time such a library may be increased by the .:■ tion of many equally good books, but the above will answer all practical purposes.
In order to fully profit hy such a course the Student will find that it is a true economy to possess for her own personal use a full set of text-books bearing upon
4o
NURSING
the various subjects. In addition, she should habitu- ate herself to utilize the opportunities for more ex- tended reading furnished by the reference library. Carefully prepared sets of notes on lectures should also be kept. Nurses will find such notes of much value for future reference since they can thus readily review the essential points of a subject when text-books are not at hand.
Unless system and order in teaching is first estab- lished and a proper consideration is given in the proper place to so valuable a group of subjects as are covered in the preliminary course, much of the reason for and the value of the principles and practice will be lost or at best only superficially understood.
In reading any work upon the principles of nursing the student must at once realize that only the ground- work or the underlying laws governing each lubjeel can be presented and that this knowledge must be sup- plemented by much practical work. In the following pages it has been tin- aim to present such principles in as clear a light as possible, so that the reason for the practical steps may be (Ik- more readily followed, and the student may come to realize that the nursing of the sick from the professional standpoint means the prac- tu.'.l application, Step by step, of certain principles. Above all. she must understand that only through the practice <>f sound teaching can she arrive at skillfulness and thoroughness in her work.
FORM OF REPORT 41
FORM OF WEEKLY REPORT OF THE PUPIL NURSE
Date
Name
Ward Class
Thoroughness in work
Interest displayed
Powers of observation
Punctuality
Neatness
General attention and kindness to patients, disposition
General deportment and behavior
Executive ability
Strong points or weak points in character and work, and any marked peculiarity
Health
Improvement (if any) General Remarks :
Head Nurse .
A monthly report to be given to the nurse may be made up by the superintendent from the above.
Marking on the various subjects taught and on practical work ii of course continued throughout the entire time.
CHAPTER II.
Economics of the Hospital Ward, Free and Private.— Construction. — Furnishings. — HvCBMtc A h r a n c e- ments— Ward Supplies. — Ward Worx.— Daily Sani- tary O.se op the Ward, op the Beds and Blankets.— Care of the Ward Utensils. — Personnel.
With the increasing development in the science of medicine, and partirularh in the field of bacteriology, and with the conviction, which is becoming recognized more and more, that thoroughly clean surroundings and pure air arc absolutely necessary for the recovery of :is. hospital construction, arrangement and equip ment have become subjects of serious consideration especially to the medical and to the nursing profession. For thi* reason it is neeessars that a trained DttffK should have some practical knowledge of the plans and arrangements of modern hospitals, for there is nothing in or about a ward or sick-room that docs not directly or indirectly affect the welfare of the patients, the rules that hold good in hospitals can be applied. With some modifications, to private dwellings. In pri- vate nursing tlu nurse may be the only one in the house who realizes that there may be something wrong with the sanitary arrangements which urgently needs to be corrected. To become familiar with the subject a l"Vi,d course of lectures and demonstrations dealing
with hospital cositmction, heating and Mutilation, is
first necessary, the knowledge thus acquired being put into daily practice later on in the hospital.
THE I'VHUC WAKD
43
The greater portion of a general hospital is given up to the wards for free, or practically free, patients, tat in a great many there arc, besides, accommoda- tions for :i limited number of private patients. The average free ward ought to contain not more than from twenty- four to thirty beds. The beds should be separated by a distance of at least three feet, and each patient should be allowed about sixteen hundred cutnc feet of air space. For a ward Of this size there should not be leu than MM bath-room, one lavatory, two closets and. if possible, one room set apart to contain nothing but the slop- hopper, rackf Ear ImMmg vessels, .mil shelves for urine jars and catheter bottle* It is de- sirable to have a separate room for a linen-closet, an- other for : nt.«" clothes, one that can be used as the nurses' work room. I imtl] ward kitchen, a dining room and at least two private rooms to be used for ex- tremely ill rious <n d vini,- patients, SO that they may be removed at once from the ward. The effect caused by the death of a patient in the midst of others is, to say the least, not encouraging.
For a surgical ward there should also be a room apart for changing dressings, putting on plaster and other surgical work. This room should con- thc ward dressing-table, the various solution-.. ointments, bandages, dressings and other appliances. Where such an arrangement is possible, a great deal of time is saved for the surgeons and nurses ; the pa- tients are relieved from the sight and sound of much suffering ; the ward is more easily kept neat and clean, and there is much Icj< fetching and carrying of appli- ances. For a medical ward a corresponding room could be employed for examinations and .special forms
44
XU/tSLVG
of treatment, such as lavage, irrigation of the bladder and aspiration. Here also could be kept the various appliances for counting the blood, and for examinations of die various secretions and excretions. I sary articles of furniture in such a ward arc, besides a bedside table and a comfortable armchair between every two beds, three or more •. li< < 1-chairs for convalescent patients and two ward tables. If possible, it is best 10 llftVC a room opening out of the ward which cu be used as a ward office and in which the medicine closet may be kept out of sight of the patients. Such an ar- rangement will also remove the temptation from pa ticnts who might be inclined to help themselves to stim- ulants or poisons. The walls should be hard finished and painted some pretty soft color; usually pale green or buff is chosen. If one room can be set apart as a day room or sitting-room for convalescent patients, it should be fitted up with lounge*, a bookcase filled with books, plenty of games, plants and flowers and bright rugs; if such a room cannot be obtained, the books and games must be kept in the ward.
Although it is desirable for hygienic reasons to have as little furniture as possible, run! that of the simplest kind, the appearance of a ward can be greatly improved by having potted plants placed in the windows or in group*. They are harmless and are a source of great pleasure to the patients. They need not add much to the ward expense, for the patients or their fru-iuls are often glad to contribute a plant to aid in making the room look bright.
The private ward is usually simply 8 hall or floor divided into a number of rooms communicating with each other bv means of sliding padded doors. In a
THH PktVATE ir.lA-/)
45
litil, i.iol: pi these rooms should be a model sick- room, in respect to location, sanitation, access* isola- tion, and water and toilet conveniences. It should be of ample sire, away from noises, have plenty of light and sunshine, and be capable of being thoroughly di Sued should be not less than two well fitting win- dows in SUCH I room, unless the BUD has free access to it. when one large one will be sufficient. If there are Wards or rooms in use above or below it, special care should be taken that the floor is deadened so as not to convey sounds. The higher up the room is situated, the better it is for fresh air and ventilation. Kach ward or private room should have an open fireplace. The walls and ceiling should always be hard-finished and painted, so as to allow of frequent trashing ; a hardwood or non-absorbent floor is also ible. In most cases of acute illness it is better to have little or nothing in the shape of pictures, as they are simply dust-collectors. The arrangement of the furniture also requires consideration. The bed should be of the single or three-quarter size, moderately the wire mattress being twenty-four inches from the floor) and placed so as to be accessible from three sides, away from the door, and in such a position that the light from the window falls pleasantly upon it. The bedside stand should be on the side next the door, the wardrobe behind the door, the dressing bureau on the side or in a corner where the patient cannot sec into the mirror ; th itul on the other side of the
room near the bed; two ordinary chairs, a cane or wooden easy chair, a small table, a screen, a ther- mometer, a lounge and the toilet china Complete the fur- nishings. Everything should be in good taste and as
46
NUKSING
dainty as possible, but must be of an absolutely simple character; intricate and elaborate carvings and hm-h ings upon hospital furniture are to be condemned. Heavy woolen rugs or carpets, upholstered chairs, pic- tures and bric-a-brac must not be permitted, though, unfortunately, such furnishings arc still not infrc- iiii uIs found in private hospitals and endowed rooms. This surplus not only entails useless expenditure, but is really harmful, and a nurse who understands the value of cleanliness will do all in her power to introduce B hygienic method of furnishing sick-rooms. A sim- ple room such as we have described can be made to look pretty and inviting by the addition of rugs, cur- tains and chintz coverings for the lounge and easy chair. A bedside mat and one or two other rugs, large enough to give an air of comfort and color to the room, but small enough to be easily taken up, n. and cleaned, are all that should be allowed ; art nigs answer the purpose well, but when dealing with infectious or contagious diseases even these should be prohibited. Dark green holland blinds are the best for shade; small white curtains of some soft washing material at the windows give an air of finish and cleanliness. All heavy articles of furniture should be on casters, so that they can be quietly and easily moved. Rubber tips should I* used for the legs of beds and chairs. In a private house an adjoining room should be set apart in which utensils, medicines and everything 'lis;n;reeably suggestive can be kept out of sight of the patient. N'oiscs such as the banging of doors, loud talking, the rustling of skirts and aprons, or the creaking of shoes, should not be allowed to dis- turb the sick-room. A nurse's dress should be free
THE PRIVATE WARD
41
from starch ; her voice should be low. quiet, but distinct. It should never be allowed to be heard beyond a few feet. Sitting in a rocking chair should not be indulged in. Coal can be put on the fire wrapped in paper, and a wooden ash shovel .ml poker may be used in place of those made of metal. Attention to all such details arc aids to the puium -. recovery.
The room should receive a very careful cleansing between the departure of one patient and the ad- mission of another. The windows should be opened wide to the fresh air and sunshine; the blankets, mattresses and pillows should be sent to be steril- ized and then hung in the sunshine and air : the walls of the room should be brushed, the bed-frame, bureau drawers, wardrobe and other furniture washed with soap and water, and the floor and windows cleaned. Entirely fresh bedding, linen and curtains should be used. Fumigation should be employed after any very unpleasant or infectious disease.
A nurse in training should try from the very be- ginning of her work to school herself in hab- its of observation: she may do this best at first by noticing the condition of the ward, whether it is orderly or disorderly, and what she can do to put things to rights. She should never pass up or down a ward without training her eyes to observe the condition of the patients, beds, tables, chairs and window-sills. This may be done by looking on one side on going up, and the other side on coming down. If there is anything out of order which may be right- ed in a moment, she should not fail to attend to it ; and if each nurse were trained to tin's habit, there would
HU/tS/NG
not be the least necessity for a ward ever to appear out of order. It is also imperative that whatever she uses should be put away in its proper place when the work is finished. If each woman as slie enters the training-school would take this one precept to heart, it would save many unnecessary footsteps and much val- uable time, not only to herself, but to all those who work with her. Rut sad to say, one is obliged to em- phasize over and over again, to class after class, the importance of returning to their proper places things which have been used. If a sheet or towel or night" dresfl is needed from the linen-room, it is not necessary to pull down and leave in disorder a whole pile in order to get the one wanted. If a medicine-glass is used, it should be washed and put back in its proper place at once before the nurse goes on to something else. If little details such as these arc disregarded, but little time i- saved at the moment, the work is in- creased instead of lessened, and after all at the end there must a general tidying-up time without the sat- isfaction of always having an orderly ward.
So, then, we repeat that the two habits of order and observation are most essential points to be cultivated in the beginning of a nurse's training.
In addition to the furniture already mentioned as HTV in a ward, there arc various other articles de- sirable, such as invalid bedside tables, wheel-chairs, extra lounges and rocking chairs, the number of which must depend upon the income of the hospital. One should try, at all events, to have a standard number of each thing, so as to be able to know just ..hat < tie has on hand and what has to be accounted for; any other plan will lead only to confusion and cxtrava-
FVRMSHIXOS AND SUPPLIES
49
gancc. Just here, a word will not be amiss to nurses in general upon care and economy with regard to hos- pital supplies. With these the nurses have more to do than anyone else ; they are the stewards, and upon them the responsibility of seeing that nothing is wasted or used extravagantly. For instance, the laundry- work could often be greatly lessened if nurses were more careful when changing beds and using towtis; the gas bill could be reduced if they would renu ml i I to turn down or put out the gas when it is not needed or when hall a fume would do insteid of a full one: alcohol, drugs, milk, and food should be ordered only in such amounts as are necessary, and one should be economical, although not parsimonious, in their use. Two Kim! i... s should never l>e put OB where one world answer. In all these ways the nurse may become a liberal contributor to charity in that through her efforts two patients can be cared for where otherwise only one could be supported. An accurate knowledge of the ;is well as of the amount of the materials in use is therefore necessary.
With a limited number of some articles one can man- age very well, but of such things as linen, toilet and dressing basins, and vessels of various kinds, there should be a liberal supply. In the average ward ac- c modating thirty women the standard linen-list may- consist of the following articles:
Blanket* (white) .... 72 Nightingales 1a
Blankets (gray) .... 12 Nightgowns 144
Dresses (women's) ... 24 Pillow-cases 144
Dusters 12 Pillow-cases (rubber) . . G
Nat>k i us (table > .... Co Petticoats 18
Napkin* Urayi 48 Rubber j (bed) 30
4
SO
AWN/.'..',
Rubbers (long black) . . 3 " (dressing, med- ical ward) 6
Rubbers (dressing, surgi- cal ward) 13
Stockings, pairs .... 48
Slippers 24
Spreads 48
Sheets (large) 144
Sheet* (draw) 120
Table-cloths 6
Towels (patients' (ace) . I jo
Towels (bath) " (tea) .
(roller) . (dressing) (doctors') (lavatory) (medicine)
Wash-cloths . . .
Wrappers ( flannel 1
Vests (flannel) . .
Pillows (leather) .
PUlows (hair) , .
13
12 48 24 12 12 40
6 34
J6 36
With suitable modifications the same list will ap- ply to the male or children's wards.
A general Hncn-book for all the wards is kept in the central linen-room ; in it is entered a list of the linen originally given out to each ward. When a ward is once supplied with its full quota of linen, no new articles should be sent in except by the system of ex- change. Thus, for instance, a worn-out garment may be replaced by a new one, but the new one should 11 . 1 r In- given out until the old one has been returned. Exchanges should be made throughout the hospital on every seventh day or the first of each month, as is most convenient, and during the week or month each MUM should lay aside whatever is worn out or needs mend- ing ; on the first of the week or month the superinten- dent looks these things over, and those condemned are listed and numbered. They are then sent to the central linen-room, the lists are verified, and the defective and worn-out articles are replaced by others. For general ward supplies, such as dishes, soap, matches, brooms or brushes, a requisition should be sent in once a week; a small book is kept in each ward for this purpose, and
•..':'•■ .'- ••;.— . :
: SIS* '•• Wl •' "::-: ■'• :
" • • • •
ward srrruF.s
every Saturday morning the head nurse writes in it a list of the new articles required, and adds her ex- change list of worn-out or broken things. The super- intendent, after going over this list carefully to see that economy is being practised, hands it in to the gen- tore-room. Each ward keeps its special basket, which is replenished according to the requisition-book. and returned to the ward on Monday morning. The head nursi .If, sees that what has been
sent corresponds with the list in the book, and if the • are correct signs a receipt for them. At the same time on Saturday morning lists of surgical supplies and hospital stationery needed for the week should be handed in to the superintendent.
For the patients' tot!) i MCh nurse should be supplied with her own loilet-basket. (See Plate I.) This should be made of strong wicker, thirteen inches long, nine and one-half inches wide, and four and one-half inches deep. The requisite articles are a hair-brush, combs (fine and coarse), small mouth-wash cup, whisk- broom, soap-dish, three small jars for boric acid, oxide of zinc powder and vaseline; three six-ounce bottles, one containing alcohol for rubbing the back and limbs, one ammonia for adding to the bathing water, and one listcrinc or some pleasant mouth-wash ; besides these, there should be a rubber cloth, three-quarters of a yard square, to be used for protecting the pillows, sheets, etc, when a patient is being bathed. Nothing more is necessary, nor should anything else be allowed, as the baskets must be uniform, so that when inspection day arrives the contents of each will be found pre- cisely the same. Each nurse is held responsible for the neatness of her basket. All necessary articles are in it
5*
NUKS/XC
when it is given hor, and after this she must attend to keeping up the supply. Worn-out articles arc put on
tin- ward exchange list bj the head nurse and their
places supplied by new ones, but anything lost must be replaced at the expense of the loser. Nothing in the waj of ribbons or binding is needed. The baskets should be arranged in such a manner that they can be
kepi absolutely clean, Since each nur.se is supplied
with one. there is no chance for any nurse to complain In is unable to leave her patients in proper con- dition because the general ward toilet articles are in use or because some of them cannot be found. The cost in the beginning is considerable, the price of each basket without the contents being about 50 cents; but they wear well and if proper care is taken of them at the ■■nil of the three years they can be passed on to the next clas.-.. I'.j having a proper number much time and trouble arc saved and better work is ensured. In addition each mihm- should be provided with dressing scissors, dressing forceps, a probe and a pin-cushion.
The ward basket should contain tilings for general use in the ward, such as a pin-cushion, sterilized wooden tongue-depressors, a tape-measure, a dressing and dissecting forceps, spatula and an auscultation towel.
The daily cart of the ward must come first. The probationer and nurse go on duty promptly at the ap- pointed hour in the morning and begin work at once. These first minutes in the morning are precious, and no one should spend a moment in pausing to chat with the night nurse, who perhaps is a friend, or with her fellow-nurses. The ward discipline in this respect should be very strict. The head nurse is there to over-
CAKE OE THE WARD
53
see things in general and her own particular work should occupy each nurse at this hour. The proba- tioner begins by giving the side of the ward under her care a general Straightening up, unless it is air. order: the chairs arc put in their proper places, un- necessary tilings' removed from the stands, and the coverlets all straightened on the beds. This takes but i Pew moments to accomplish, and gives an orderly ap- pearance at once and makes the remaining work less confused. It is necessary to have the wards neat, and in good order by the time the physician enters to make morning rounds. The hour for round- ...n, , fa different hospitals, but as in many nine o'clock is the let, for the sake of convenience we will consider this as the hour, The convalescents' beds have been already aired by the night nurse and are ready to be made up al Once The main sweeping and brushing
tl : been finished by the ward maid, the daily ward ■Justing comes next in order, but it will of course be
-.•Me to have it all thoroughly done for early rounds. This dusting simply removes the twenty-four hours' accumulation of dust. For this purpose a damp cloth wrung out of a basin of a weak solution of car- bolic acid should be employed. All the chairs, tables, iw-sills, bed-heads, bed-frame and ends
should be gone over in this manner, care being taken to change the water frequently. The dust-cloth should afterward be washed out in hot soap and water and wrung out of a 1 .20 (5 per cent.) solution of carbolic
l.efore being hung up to dry. The bedside stands sliould be examined each day, and nothing left in them but convalescents' clothes ; everything in the way of food, extra clothing, pasteboard boxes and other ac-
S4
NVfiS/.\<7
cumulations should he removed. As there is always a certain amount of dust or fluff under the beds after • bed-nuking, before beginning to dust, the probationer should lirush under tin- beds a second time with a flan- nel fastened over a broom or a long hair brush. This brushing should be repeated in the afternoon after uin ner. Where good nursing prevails a collection of dust is never found under the beds or upon a sick-room floor.
A -\<trd door should Ik- made of hard wood and tli.u rendered impervious to absorption. Scrubbing hospital floors is a mistake, for in this way impurities and germs are constantly being absorbed by the wood in stead of being removed ; as a result, as soon as the floor dries the dust given off from it may contain the very germs that the washing is intended to remove. Hard wood, finished with shellac varnish, and then treated with a mixture of turpentine and paraffine, makes a beautiful floor, and a perfectly smooth, resist- ing surface, upon which the dust only rests and from which it can be easily rubbed off. The turpentine is also cleansing, linn *' dl solves and removes spots or stains ; it has also disinfectant and deodorizing proper- tics. To make this preparation :
Take of Turpentine I gallon
1'arafnnc 6 ounces
Allow to stand for twenty-four hours till the paraflinc is dissolved, then add one ounce of soft soap before U mixing ill thoroughly.
It can be applied with a pad of flannel fastened on an ordinary mup vtick. With this the floor is to he robbc I all over, and before the hard robbing for polishing it should be left an hour or so until the turpentine is ab-
WARD CLE A SI. SO
55
sorbcd; it is then polished, the rubbing being always in the direction of the grain of the wood, with a heavy polishing brush covered with flannel and weighted with from twelve t<> twenty-five pounds of lead. This application should be made every week or ten days, the floor being brushed up every day with a hair floor- In brushing a hospital floor it is important to raise as little dust as possible; by fastening a flannel over the brush or broom this danger can be almost en- tirely obviated. If it were no* so expensive, a smooth India rubber tiling or floor covering would be ideal, as it is noiseless and clastic, but not absorbent or slippery.
After the ward is in order the flowers and plants should be cared for, and then the probationer should give her attention to that special part of the ward for which she is responsible: if it be the lavatory, she should sec that all bottles, vessels, etc., are clean and in their proper places, that the shelves and slop-hopper arc in order and the bed-rubbers cleansed. If tl»e maid does not do her work well, the attention of the nurse in charge should be called to the fact. It is always best to have the criticism come from one in authority, but it is necessary that the matter should be reported. Otherwise the probationer may be marked for untidi- in the lavatory or any other department entrusted to her charge.
This daily care keeps the ward in good condi- tion, but it is not sufficient to make a more par- ticular and thorough cleaning unnecessary. When we stop to consider the number of patients with their various dii ho pass through a ward, with, say,
an average of thirty inmates daily for six months or a year, besides all their friends and the people who come
56
NUftS/XG
mi I go <luring that time, wc can easily realize how necessary it is to be constantly on the alert with pre- cautionary measures in the way of a thorough cleaning hmild be clone daily, weekly, semi-annually and annually. Of tlic first we have already spoken. In tin weekly cleaning the bedside chairs and the win- dow-sills should be washed thoroughly with hot water .mil green soap, the scrubbinp-briish being used vigor- ously. One day should be set apart for this purpose, each nurse looking after her own division, and on a second day a thorough dustinp and cleaning of the beds is undertaken. The bedsteads are washed with .1 solution of carbolic acid, and the mattresses arc well brushed with a whisk broom. This precaution is ab- solutely necessary in free wards, where vermin are not infrequently brought in by patients or their friends ; for if these pests arc once allowed to get a foothold, the task of getting clear of them is difficult. A bed- bug should never be seen in a hospital ward, and tins weekly care of the beds is the only way by which these intruders can be kept out. The Mflie precaution should be taken in private wards, and the patients' trunks should not be allowed to remain in the rooms, but should be unpacked and taken to the trunk-room.
The most thorough cleaning of the ward should be done in the spring, and then, if possible, it is better to transfer the patients temporarily to another ward or to a tent ; otherwise wc shall have to select a time when the occupants are few. Walls and ceilings should be thor- oughly washed down and repainted, all the wood-work well cleaned, windows and chandeliers polished, and the bedl disinfected thoroughly with carbolic and The floor is scoured at least twice with green soap, hot
WARD CLEANING
57
water and brush before being paraffined. Every corner and every portion of the ward should receive ilii^ I rc;it tin ill.
Besides the regular weekly cleaning that it receives, it should be the rule when a patient is discharged, always to prepare the bed for the next occupant by washing it thoroughly with a solution of carbolic acid. Bichloride should never be used for this purpose, as it corrodes and destroys the iron. The mattresses should be sent to the sterilizing oven, or thoroughly brushed and left for some time exposed to the open air and sunshine. Blankets are treated in the same way. When these arc too soiled or for any reason are unfit to be used again without being cleaned, they should be sterilized and put away until a number have moisted from the various wards, ud then all sent at once to be cleaned, instead of being washed at the regular laundry. When frequently washed in the ordi- nary way blankets become hard and stiff, not to men- tion the fact that they do not wear well.
The ward utensils, such as the patients' basins, bed- pans, and urinals, besides the attention given them daily, should be well washed out with green MOD on a in day of each week and left in boiling water for an hour. The general bath-iub is to In- li-med thor- oughly after each patient. Above all. the ward is not to be made a storehouse for unused or broken articles of furniture, for, unless the rule be rigidly adhered to that only useful articles and those in good repair ST€ I in the v.. ml, we are sure to be hampered by an accumulation of rubbish. These arc domestic de- tails that must be looked after carefully and systemat- ically, not in a spasmodic way, for they all have indi-
58
NUKSliVG
rectly much to do with the patients' welfare. In fact, any woman who lacks cither the will or capacity to perform these duties intelligently and thoroughly should not he permitted to undertake the secmingly morc serious responsibility involved in the personal patients.
nursing personnel of a hospital ward usually consists of the head nurse, the assistant nurses, the pro- bationers, and in the male ward, an orderly.
If there is an orderly in the ward, his duties should be carefully defined. He will be expected, in the male ward, to give patients their first baths in a tub if they arc in a condition to be bathed, and to put them to fad ; to carry all vessels to and from the patients; to give enemata to convalescent men ; to collect the sputum-cups and keep them clean ; to do the ward cleaning in a .systematic manner ; and to assist in any heavy lifting.
CHAPTER III. •
Hyciikc or the Sick-koom ano Ward — Vrktilation— TcMmiATUKE — Limit.— DISPOSAL or ExatrrA, Sui 1.1:0 Diuessincs and Soiled Linen.
A real appreciation of the causes of disease and the care of the sick is impossible for anyone who docs not possess a good understanding of the laws govern- ing health. Hence it follows that a course in hygiene and its allied branches, bacteriology, practical chem- istry, physiology and the elements of physics, should precede the practical BUItiflg of the patients.
No department of a nurse's work should appeal more forcibly to her than the hygiene of the sick-room. Sin- should thoroughly grasp tlie genenl priocipltt which underlie the subject, and endeavor to apply them in the minutest detail. Thoroughly clean sur- roundings and a constant supply of pure, fresh air are the ideal conditions, but the question how these can best be secured may at times tax our ingenuity to its utmost. In well-planned hospitals these desiderata usually been fully pMviUd for. and it will be the nurse's duty simply to sec that the means to tin in so far as they are entrusted to her care, receive intelligent attention.
Nurse* are guilty of culpable inattention who slight this daily and hourly feature of their work. A nurse should constitute herself, as it were, the ward ther- mometer and barometer, and train her senses to note any change in the ward atmosphere. She should
S9
Mf&SING
never come into the room or ward from the outside hi without noticing particularly whether any disagree- ;ill:' i mIch he present or if the air be heavy and close; and if there be any suggestion of impurity. steps should be taken at once to remove the cause. Even in the absence of the means usually employed she should be able to detect by her own sensations a temperature too high or too low, and air which is damp or chilly. It is just U Important to charge each nurse in turn, for a certain length of time, with the responsibility of looking after the ward hygiene as it is to detail her to administer the medicines at the proper hours. Suitable hygienic conditions will sometimes do more to cure patients than the admin- istration of drugs : and fresh air is as necessary as food. The open-air treatment has been given a thorough trial in cases of tuberculosis and many other forms of disease; and the benefits to be derived from it arc undoubted. Except in extremely inclement weather a good nunc can keep her patients warm and comfortable even when out of doors, by protect- ing them well with flannels, blankets, hot-water bottles, and with out-: until only the mouth, eyes and
nose arc visible. Providing these comforts are patients will do far better, if kept in the open air from an early morning hour till sunset. or even during the night as well as the day.
-ils now have some sort of a winter garden or sun parlor, so that, when sitting or lying out of doors is impossible, patients can obtain the benefits to be derived from sunshine and light as well as a change of atmosphere.
ler the condition of a ward wholesome, it
HYGIENE OF SICK-ROOM
6l
is necessary not only to regulate its temperature, but also to provide for the ingress of a supply of fresh air whenever it is needed. Care must be taken that the ventilation flues for removing any accumulation of im- purt' air are opened Uld dosed at the proper hours; that any disagreeable odor is removed ; that deodor- izers, if they are in use, are renewed; that the waste
pipes and kitchen links ire properly cleaned and Bushed
daily, that no soiled or infected linen and no soiled clothing or dressings are left standing about in uncov- ered receptacles, and that all vessels in use are kept thoroughly cleansed. i\'o nurse can do this properly unless she trains herself to be always on the alert to see that no rule of hygiene, which it is possible to ob- serve, is broken : and here, again, much will depend Upon the acquisition of the habit of observation.
The limits of a text-book on nursing arc necessarily too narrow to permit a full discussion of so important a subject as hygiene. It will be possible only to tomb upon the fundamental principles and to describe in brief some of the most important methods.
The firtt division of the subject to be considered is
ventilation, but to clearly comprehend its importance
11 1 first understand the conditions that call for it.
Air, being a mixture of colorless gases, is quite ble, but changes in its composition arc readily detected by its exhilarating or depress: the system. As air occurs normally in nature, it con- sists of 20.63 parts of 0 mixed with p8> p. of nitrogen. Besides these two substances there is s some water in the form of aqueous vapnr, and some carbonic acid gas. The quantity of aqueous vapor varies with the temperature, but on an average
6l NURSING
does not amount to more than about 0.84 per cent, and in the open air the proportion of carbonic acid gas (CO,) is never greater than 4-100 of 1 per cent. Of the two gasea of which the atmosphere is funda- mentally composed nitrogen is of no biological sig- nificance, except in so far as it dilutes the otherwise too energetic oxygen, upon which all members of the animal and vegetable kingdoms depend for the per- formance of those functions which in their combination we recognize as life. When we remember that air is a mechanical mixture and not a definite clicmical compound, we cannot fail to be struck with the con- stancy of its composition. Normally, carbonic acid gas is being poured out into the air from ninny sources: men and animals breathe in oxygen and breathe out carbonic acid gas, and in the combustion of wood and coal large quantities of oxygen from the air combine with the burning carbon to form the same substance (carbon dioxide, carbonic acid gas). This production, which might otlu excessive, is partially compensated for by the action of plants, since it is well known that trees and plants in their growth split up the carbonic acid gas which they find in the air, retaining the carbon themselves and setting the oxygen free. " It will be readily understood that where anything interferes with the natural methods of purification of the air, as must be the case where people are hived together in cities and manufacturing towns, the proportions above given may be seriously altered by the introduction of impure gases, smoke, dust, and organic matter of various kind>.
Substances containing carbon arc present in the
HYGIENE OF StCK A'OO.V
«3
and it is through the oxidization of these, with tlii! formation of carbon dioxide (a process of com- bustion), that the body heat is maintained; hence it is necessary that the air with its contained oxygen should enter the body freely in order that these chemical changes may proceed satisfactorily. The longs are the organs set apart to render possible the free interchange of the gases of the blood with those of the external air. Each time a breath or inspira- tion is taken, a certain amount of oxygen enters the lungs; hence it passes through the walls of lli>' r ij.il laries (which ramify over the air-cells of which the lungs arc composed) into the blood, by which it is distributed to the tissues. Carbon, bunting slowly or quickly, is changed finally, as we know, to carbon dioxide. This finds its escape into the outer air again principally through the lungs, so that with each ex- piration the air breathed out is charged with a cer- tain amount of impurity in the form of carbonic acid gas. Moreover, certain extremely poisonous organic substances, of the nature of which we are as yet in complete ignorance, accompany the carbon dioxide and add materially to the deleterious effects of the expired air. Unless some provision is made to remove
impurities, instead "f breathing in fresh, m- contaminatcd air, our patient will take in again the same impurities that were breathed out; hence one great necessity for ventilation. Again, organic mat- ter is being constantly given off by the skin, as well as by the lungs, not only in the form of vapor, hut also as small particles of waste or decayed tissue. The atmosphere, besides containing these impurities coming from the bodies of men and animals, is in-
ft
64 NURSING
fluenced more or less by the different localities and surroundings ; thus in some places where there is much decayed vegetation, in swampy or marshy tracts of land, in overcrowded communities, where dirt in dark corners and in vessels is allowed to accumulate, where refuse and offal of every description remain uncovered, — in all such places the oxygen in the air i> decreased, and tin air itself il COntSmiaated with poisonous gases and compounds, thus rendering it unfit to breathe. The burning of illuminating gas is another factor to be considered, since it deprives the air of its oxygen and gives in return gases unfitted for respiration ; thus in the burning of one cubic foot of ordinary gas eight cubic feet of fresh air are used up. The same remarks apply to the combustion processes in stoves and furnaces.
These, then, are some of the conditions which healthy people have to encounter in breathing the air al»>nt them; it is obvious that the conditions become much more serious in rooms or in hospitals where disease is continuously present. The quantity of im- purities given off from diseased bodies and from the excreta is enormous, so that the matter found in the air of the sick-room and in the dust which collects upon the furniture is likely to contain a large pro- portion of organic matter, and not seldom the germs of disease.
The necessity for good ventilation and thoroughly clean surroundings thus becomes at once apparent ; in a word, the foul air must be replaced by pure, fresh air.
The methods of ventilation may be divided hit" two great classes, natural and artificial. In each case the
VENTILATION
65
air must be changed without causing a draught The smaller the space through which the air is admitted the greater danger of having draughts, and the smaller the room, the more quickly and easily docs the air become impure. The amount of pure air which should be supplied for each person in an hour is 3000 cubic feet — »'. e. about 1 cubic foot per second. The volume of a given mass of air varies, like that of all gases, with changes in temperature and pres- SUre : thus gases expand when heated and contract when cooled or when subjected to increased pressure. Natural ventilation is chiefly dependent upon three factors, the action of the winds, the movements pro- duced by the unequal weight of the different air- strata (brought about by temperature and pressure changes), and the diffusive power of gases. As we said above, heated air expands, and so in a room heated in any way the air mud exptnd more or less according to the degree of heat. The surplus will escape in various ways through doors, windows, and crevices. The outside air, being heavier, will now have a tendency to enter the room and displace the lighter air, but this air which enters becomes heated in its turn, and thus two constant currents of air, one going out, the other coming in, are established. This will occur, of course, only when the temperature of the outside air is different from that of the inside air. These air-currents may at times be so rapid as to produce draughts. If the room has the same temperature as the outside air. there will be no ventila- tion or change of air. In summer, when windows and doors arc all open, the atmosphere is much alike
66
AY W.S-/.W
both Intidc Mid out, and for any change that is pro- duced we mast depend upon the wind.
But in order to have good ventilation it is necessary that the air which enters should penetrate into every part of the room, and become well mixed with that already there. In the case of winds or air-currents produced by temperature variations, if the velocity be great, the fresh air may enter one portion of the room and pass directly through and out again, thus affecting only the small portion of the air coming directly in its path.
Diffusion of gases goes on perpetually according to the well-known physical law.* The air-currents will be toward that part of the room in which the air is warmest, as they always flow in the direc- tion of the least resistance. No matter into what part of the room the cold air enters, it will alwa\s fall. In ventilating by means of windows the entrance of the fresh air and the exit of that which has been exhausted should be regulated by opening the win- dows from the top only and on opposite sides of the room, one toward the direction from which the wind blows and enters, and the other away from it. In this way any draught that may be caused will be too high up to harm the patients, unless a door should be left open at the same time, so that an opposite CUf rent is produced. The patient's bed must be placed out of the line of air-currents. If this is not possible, the patient must be protected from draughts, and pos- sibly a pneumonia, by means of screens, the head of the bed being especially guarded. The old popular idea
'Gun diflutc inve»»ely u the iquuc root of ibeir den»llle».
VENTILATIONS
67
that draughts are dangerous is founded on fact no less than is the modern idea that an abundance of fresh necessary and helpful. A nurse has been guilty of gross neglect of duty when her patient contracts pneumonia through exposure to too severe currents of air. Another advantage in having the cold air enter at the top is that it will become slightly warmed in its descent, and not be so apt to be felt by those who are up and about the room. When the windows are open, however, care should be taken not to have a patient in bed directly uiuk r the one through which the air enters. If there is a fire-place with a fire in it. it will not be necesary for the second window to be opened to let out the heated air, as the draught created by the fire attracts the air to the fireplace and so up the chimney. The fireplace is considered the best method of extracting the air, but this mode of ventilation is suitable only for small wards. Where there is only one window in a room, or where there arc two. but both arc on the same side, a fireplace is necessary, and in summer a burning lamp or candle should be kept standing in it to warm the air and produce an upward current.
To avoid draughts and to secure a constant supply of pure air in a room, various artifices be resorted to, some of which are more particularly applicable to private nursing and dis- trict work, where a nurse often has to invent her own arrangements and explain away a great many objections. A simple way is to raise the lower sash of a window six inches, and place a board across the opening below ; the air will then enter between the sashes and lu directed upward, where it becomei
yt'KStS'G
diffused and no one in the room is subjected to a draught If the sill of the window is deep, the sash may be raited until its edge is even with the surface of the sill, and in this way the same end is accom- plished. In a room with only one window, a pane of glass may be taken out and a piece of tin or paste-board may be so placed that the current will be directed up- ward. As another expedient, a window can be opened in an adjoining room, which in this way is filled with fresh air, the door into the sick-room being afterwards Opened to admit it. The patient may be covered up. head and all, for a few minutes two or three times a day, while all the windows arc thrown open and the room is thoroughly flushed. Natural methods of ven- tilation are those chiefly employed in private houses. and the arrangement of some of the simpler plans very frequently devolves upon the nurse. This is quite right, since she is on the spot at all hours, and should understand just what is required and what is the best thing to do in any particular case. In institu- tions, however, both natural and artificial methods are used, for no matter what artificial means may be resorted to in the winter for heating and ventilating, in the summer doors and windows are freely opened, and the natural forces are depended on for the distri- bution of air. Here, on the other hand, it is not necessary for the nurse to plan, so much as to fulfil, am] it is her duty to acquaint herself with the exact method employed in the particular hospital in which she works, and to make sure that whatever part of its fulfilment falls to her share is faithfully carried out
In making our arrangements for ventilation it must
VENTILATIOX
69
not be forgotten that the preservation of an tven temperature is all-important. The system by which ff.-li .lit can !»• introduced into the room at almost any degree of temperature desired by passing it over hot-water coils or by admitting it without being heated at all, while at the same time the foul air is removed by ducts, is by far the most complete method employed as yet. The ventilation and temperature of the ward can be regulated by proper observation and with a little care, so that while the room is kept warm enough the absence of impure air or disagreeable odors is remarkable A full description of this plan may lie found in Dr. J. S. Billings' description of the Johns Hopkins Hospital.
In order that a correct idea of the temperature may always be obtained, the thermometer should be sus- pended at a central point in the room or ward ;m<l on a level with the eyes, not too near the gas or the windows, and the temperature recorded once every hour. The frequency of such observations will assist a nurse in realizing what variations of tempera- ture may take place within an hour, and should train her in the habit of noting atmospheric changes. A record should be kept faithfully and punctually day and night ; and where the temperature is found to be higher or lower than the degree required, the next step after recording it is to remedy the condition by cither increasing or decreasing the heat-supply. It would hardly seem necessary to say this were it not a well-known fad thai nurse after nurse has been known tn pause in her work long enough to look at the thermometer, and. finding the temperature 7o°F. or 8o°F., has calmly recorded the same and resumed
7o
NURSING
her interrupted work, without at all realizing that she has performed but the smallest part of her duty. She might Just as well, in many cases, omit her patient's medicine as neglect the regulation of the temperature of the air by which he is surrounded. In the same way draughts may blow about some nurses, who, if they have not been especially instructed on this point, will have no idea that the regulation of them has anything to do with their duties. These arc minor details, but they are important ones. The ward or room temperature must be regulated a< ing to the nature of the disease, and the comfort of the patient. In fevers it should be of course lower, varying from S5*-6o" F., but in bronchial affections it should be kept at about 708 F. The mean should be from 6o°-65° F. When the temperature is found to be cither above or below this point steps should be taken to raise or lower it All changes, however, should be made gradually in order to avoid the risk of over-heating or chilling the patients.
Variations in the temperature of the air take place normally at different times in the day, it being warmer at high noon and cooling off towards night. Particu- lar attention should be given to patients in this regard between the hours of one and six in the morning, since at this time the sick, and even well people, often feel chilly sensations. It is during these hours that the vitality is lowest, and many deaths occur. At such times a patient often needs an extra blanket, a hot-water bag or a warm drink ; when the ex- tremities arc cold they should be rubbed and then wrapped in flannel. Meanwhile, the ward tempera- ture should be kept up, not by closing all windows
HYGIENE OE THE WARD
7«
and openings and shutting in the foul air, but by the addition of more heat in whatever form it is sup- plied, whether by means of a fireplace, steam, or hot air. The intelligent nurse see* to it that at any hour of the twenty- four the patient's vitality is so carefully guarded that any tendency to chilliness is promptly met
Give plenty of light and softly shaded sunshine to patients and ward, but be particular to ex- clude the glare on hot days, and do not let the sun shine directly upon the face. A south- ern or southwestern exposure gives the greatest tit of sunshine. Except in certain diseases light is an important factor in the patient's recovery as it renders the air more healthful and has a definitely destructive power upon bacteria. It is surprising how many people, in other respects very intelligent, dread the night air, and how carefully they exclude it from their sleeping-rooms, forgetting that it is the purest air obtainable at that moment, and therefore the best, provided it is not entering directly from some cess- pool or contaminated portion of the country. The ideal night light is the shaded electric bulb light. Wbcre this is not obtainable the lamps, candles, or gas should be kept burning in an adjoining room where there is plenty of ventilation.
The disposal of the excreta of a ward or sick-room is one of the most important considerations in con- nection with its hygienic condition. The sputa and other evacuations, improperly cleaned vessels, soiled lugs, and soiled linen, if not properly taken care of, are prolific sources of impure air.
Sputum-cups for patients should be made of glazed
72 tfURSMG
earthenware, straight up and down, without any corners or cracks, and provided with a simple movable cover when in use. They should be sterilized for one hour in every twenty-four hours.
Bed-pans and urinals shoidd be washed out thoroughly, boiling hot water being allowed to run on them for some little time before they are put away. Soiled dressings should be received in basins with covers or in paper bags, and at once carried from the ward, and, unless special disinfection is necessary, put into the soiled dressing can, which is made of metal and closely covered, and carried away as soon as pos- sible to be destroyed. Vomited matter or evacua- tions from the bowels or bladder should never be carried through a ward or from a room without being covered over either with a towel or rubber cloth. The rubber cloth is better, as it keeps in the odor ; it is also impervious and can be scrubbed and disinfected. If the patient is too ill to use a proper sputum-cup, the expectorated material may be received in a paper handkerchief or a piece of cheese-cloth and placed in a small paper-bag, which, however, should be burned at once. All specimens for examination should be kept in vesels closely protected with clear glass covers, so that the contents are visible, while unpleas- ant odors cannot escape.
In many hospitals, before it is sent to the gen- eral laundry, the soiled and stained linen is wash- ed out and disinfected in the ward stationary basin or slop-hopper. For many reasons such a practice is to be strongly condemned. Where it is followed, the nurses are exposed unnecessarily to risks of in- fection; time is taken up which should be devoted
PERSONAL HYGIENE
73
to the patients'; the infected material passe* vith the Into the M'wcr pipes; the procedure is not only htlv l>iit also produces an unpleasant odOT More- over, such a method of teaching nurses about tin- care and sterilization of infected material is too slip- shod and hap-hazard. All sucli soiled articles should he put away by the ward nurses into a receptacle containing enough disinfectant solution to Weep them moist. They are then removed from the ward ns soon as possible and taken to a room connected with the genera! laundry, which is fitted up with a vniti lating flue, one or two large stationary tubs, or a small washer, and abundantly supplied with disinfect- ants. Here, under the supervision and instruction of a competent teacher, the probationers should be de- tailed for duty for a certain length of time, so that in. ■, may becoiiu thoroughly instructed in the parlous measures necessary for the proper cleaning and sterili- zation of stained or infected linen. The object of all these precautions is to reduce to a minimum the scat- tering broadcast through the hospital of those or- ganic impurities which do so much harm.
Public or municipal hygiene forms an important branch of this subject, especially for nuw «ho in- tend to do district or school visiting, or who wish to qualify later as sanitary or tenement inspector!
But above all it is important that a nurse should have a clear conception of the application of the laws of hygiene to the care of her own personal health. Only too often docs the training-school superintendent find, on her tour of Inspection of the nurses' sleeping- . that more than one window has been tightly closed all night, notwithstanding the instructions that
74
NURSING
have been given. If a nurse can not realize the im- portance of pure air for herself, how much less is she able to protect the health of those entrusted to her: how little will she be prepared to combat the errors and prejudices which she will daily encounter in her work as a nurse.
The above is, of necessity, an inadequate descrip- tion of so vitally important a subject, but no pretense is made to do more than endeavor to direct the student's thoughts in the right direction. Any woman will remain superficial if she fail to utilize carefully the lectures and demonstrations on hygiene, and read for herself books that will enable her to have a deeper knowledge of the subject.
CHAPTER IV.
Bacteriological Notes. — Sterilization and Disinfection.— iniixtant Solutions.— Thi Mmiic System.— The Preparation op Solutions.— Disinfection op Clothing, Room*. Furniture, Wards, Excreta, and Vessels. — Iso- lation and Quarantine.
The subject of bacteriology as applied to the work of a nurse is too extensive to be fully discussed in one chapter of a book on nursing, and only an at- tempt will be made to impress the student with the necessity of clearly comprehending how much it de- DpOTJ her whether or not the great modern discoveries are utilized in daily life for the preven- tion of disease. Next to the physician's, the nurse's work is most important in relation to disease, its causation and prevention, for in every department of nursing she comes daily in contact with sickness in some form, and much depends upon the intelligence and care with which she carries out her principles. Il is important, therefore, that she slicn!' I ii"i only be taught carefully the fundamental principles, but Obtain a practical knowledge of the technique. of bacteriology, To accomplish this end a practical course of laboratory instruction which shall clearly demonstrate the essential principles of bacteriology essary. Didactic lectures can never take the place Mall] 1 listing in and seeing bacterial develop- ment. The beginner cannot do better than read the articles prepared by Dr. T. Mitchell Prudden, for
7S
76
mwsr.s'G
general reading in his two small books. The St of the Bacteria; and Dust and Its Dangers; also the slightly more elaborate volume by Prof. H. W. Conn. The Story of Germ Life. These might be read before attending lectures on bacteriology, and will render more interesting the practical demonstrations of the various forms of bacteria, their methods of growth, their uses in the arts, and their relation to the dif- ferent forms of disease.
Bacteria — so called from the Greek word meai rods (sing, bacterium, plural bacteria) — micro-organ- isms, germs, or microbes ( i. e. tiny forms of life), arc among the various terms employed in describing the many and widely different classes of these or- ganisms. It has been found that there are almost innumerable forms and that they are everywhere pres- ent— in the air. in water, in vegetable tissues, and con- sequently in foods. All bacteria are micro-organisms, but not all micro-organisms are bacteria. The bacteria are lowly vegetable forms, while other micro-organisms belong to the animal kingdom. Some of the latter are also of medical interest, as they are the cause of certain diseases in man and other higher animals. Although the majority of the varieties are harmless to man. it is now known that some of the most prevalent diseases, not only those which have been for a long time termed infectious and contagious, but also the so-called blood- poisoning, inflammation, fevers, and abscesses, arc caused by certain kinds of bacteria. Every form re- quires its own peculiar kinds of nourishment and suit- able surroundinga I able it to grow and [ccreue,
Da,ctcria arc found most often where both heat and : urc are present ; putrefaction cannot take place
BACTERIOLOGY
11
without them: in the decay of organic materi.nl the) play an important part, so that we shall not be sur- prised to learn that the excreta from tin body, Ihf sputa, fasces and urine, provide favorable culture- media for various forms. In crowded localities, where unclcanlincss prevails, they grow in abundance, while in hospitals they are always present, and constant precautions must he taken to keep in abeyance and. if possible, destroy all virulent forms. Bacteria ding to moist surfaces, and as long as they are in a moist condition they can not be swept into the air nor be carried from one point to another except by IQinul agents; but when these surfaces are allowed to dry, so that die organisms can be blown about as dust by the winds, then it is that they are carried and sea tut id abroad and become a source of danger. If they be introduced into wounds, they may cause inflammation or mi | iom.it ion, or on entering the body may produce blood-poisoning and various forms of infectious fever. In hospitals or wherever disease is present the means taken to prevent the spread of the micro-organ- isms must vary according as they are in a moist or dry medium. If the substance which contains them be moist, as sputum or faeces, precautions arc ta- ken to see that it be kept so until entirely removed from the ward for disinfection; or the different dis- infectants may be used at once, as some of these v, ill destroy germ-life immediately, while others will at least prevent further development and multiplica- •i ..ii for the time being. If the germs are dry, as we know they must be in the dust in a ward full of patients, care must be exercised to reduce the amount of dust to a minimum, and to remove it with-
78
At'KS/.VG
out scattering it The nurse must, therefore, learn in a very practical way how air, soil, water, food, and clothing arc concerned in the spread of bacteria, how the bacteria gain access to the body, and what preventive measures must constantly be employed on account of their relation to health, to disease and to wounds and surgical procedure*.
The measures taken to prevent bacterial contamina- tion or accumulation include thorough cleanliness, a free supply of oxygen, destruction of fomites. disin- fection, sterilization, and the isolation of infectious cases. Cleanliness in the ordinary sense of the word relating to sick-rooms and hospitals has been discussed in Chapter II, but cleanliness in relation to bacteri- ology lias a much deeper sense; and where there is reason to suspect the presence of infectious germs wc should always be sure to keep on the safe side. Thus in all suspicious cases the patient should be isolated and the cleaning done should amount to sterilization in regard to vessels, clothing and excreta.
Sterilization is effected in two ways — either (i) by the action of heat, or (2) by means of chemical agents —hut the term "sterilization" is usually employed when heat is used, and "disinfection" where the action of chemicals is relied upon. In addition to heat and chemicals for destroying germs, we depend upon the natural m ; .plied by sunshine, light, fresh air,
especially that of high, dry climates. Within the body the blood, the normal secretions and the use of certain scrums are of the greatest importance.
It has been found that while moderate warmth encourages bacterial life a certain degree of heat will effectually destroy it Bacteria are destroyed by
STERILIZATION
19
either dry or moist heat; the latter in the form of ■team is the means chiefly used, since a moist atmos- phere at ioo" C. (steam), or better at 1200 C. in a ncd apparatus, will sterilize much more effective!; than dry air heated to a much higher tem- perature. With our present appliances steam can now be obtained with little difficulty, and if fabrics be not exposed to its influence too long at one time, they are injured less than by dry heat. Dry heat is not so penetrating, and requires a longer time to do its work, not to mention the fact that such things as leather and woollen fabrics, if they be exposed to it long enough to destroy the germs, will generally be ren- dered completely unfit for further use.
The application of dry heat is a baking process; the objects to be sterilized are exposed to a steady temperature of not less than 3000 F. or 1500 C. for one hour.
With moist heat the objects to be sterilized arc Hy exposed to the steam on two or three separate occasions, the length of time necessary for the pro- cess depending, cacteris paribus, upon the resistance to heat possessed by the organisms to be destroyed. Bacteriologists teach that to entirely destroy all gcrm- lifc and all spores, it is necessary to expose whatever is to be sterilized to the steam at too" C. for three successive days for thirty minutes or more (according to the bulk of the articles) each day, and during the time intervening to keep them in a room at a tempera- ture of 300 C. The rationale of this operation is very simple; the temperature of boiling water (too0 C.) suffices to kill all vegetative forms of bacteria, but it often fails to destroy such as are present in the spore
NVXS/NC
form. In order to accomplish complete sterilization, opportunity is afforded the spores to germinate, which usually happens in one or two days at 300 C. The successive sterilizations arc intended to destroy the bacteria as they develop from the spores.
The autoclave has been introduced by bacteriologists, and is being generally adopted in hospitals, as by its use a higher moist temperature CM lie easily pro- cured. In this apparatus the objects are exposed to heat under the pressure of an additional atmosphere and the temperature is raised to 1200 C, whereby the need of fractional sterilization is obviated. One ex- posure suffices to destroy the resistant spores as well as the vegetative bacteria. For smaller articles, instru- ments, solutions and foods, the Arnold sterilizer ( Fig. 10) is most complete and inexpensive. For sterilizing bedding, mattresses, clothing and large articles, a regularly built steam disinfecting apparatus is es- sential. For public use these should be provided in various parts of large cities, but every hospital should have its own, and each nurse should understand the methods of and arrangements for disinfecting.
Another simple method of sterilizing is to boil the articles in plain water, though usually a chemical sub- stance— as. for instance, 2 per cent of sodium carbon- ate— is added to the water. Where no other means are available small articles may be steamed in the or- dinary kitchen steamer. Put the articles in the steam- er, then closely cover and place over a pot of boiling water. In very virulent forms of disease the destruc- tion of the germs by burning the furniture and cloth- ing is still resorted to.
The chemicals used for the destruction of bacteria
DISINFECTANT SOLUTIONS
Si
are called germicides; those which arrest and prevent development! disinfectants. Disinfectants ihouM al- ways be fresh, otherwise they may lose their activity. Some chemicals arc simply antiseptic, that is. they re- tard the growth of the germ but do not destroy a. while others arc merely deodorizers — odor destroyers.
With the development of bacteriology and as a re- sult of constant experiment the list of disinfectants or germicides in use is always changing, and what is to-day accepted as the most valuable drug for destroy- ing micro-organisms may in a few months, or even sooner, be replaced by a new one; statements made as to the value of the different chemicals as disinfecting agents cannot as yet be accepted as final.
Corrosive sublimate was for some time considered the most powerful germicide in use, carbolic acid com- ing next after it ; but recent investigations have shown that the action of sublimate is not so effectual as that of carbolic acid. The former, it is true, brings about decided changes in the condition of certain forms of germs, but does not, as was first supposed, always kill them. Besides, the drug is objectionable on ac- count of its intensely irritating and poisonous quali- ties. Heat in various forms is now relied upon more than chemical preparations for sterilization, but cer- tain solutions are still used for the destruction of germs or as a preventive against their development.
Carbolic Acid (C, H, OH).
One of the most efficient and most frequently em- ployed of the known chemical disinfectants is car- bolic acid. It is a product of coal tar distilled It
82
NU/tS/.VG
a high temperature, and when purified come* to us in the form of white crystals readily soluble in water, glycerine, or alcohol. Carbolic acid will not dissolve, however, in all proportions in water, so that aqueous solutions stronger than 5 per cent, cannot be made; at the same time it is a deodorizer, and is sometimes applied locally as an anxstlictic.
Solutions of a strength weaker than 5 per cent, will not destroy all germs, but owing to the irritating qualities of the substance it cannot always be used so strong, and for the skin or mucous membranes weak- er solutions arc employed. They should be made to come thoroughly in contact with whatever is to be dis- infected, and allowed to remain so for some hours. Carbolic acid is the chemical substance most frequently used for disinfecting clothing.
To mix a 5 per cent, or 1 : 20 solution the bottle con- taining the crystals is placed in hot water until these are melted; then 1 part of carbolic acid is taken, 19
parts of boiling water are added to It, and the whole is
shaken vigorously until all the globules of carbolic acid have I urn dissolved by the water. If the water be not sufficiently hot or the solution not well shaken, globules of the acid may remain undissolved — a con- dition full of danger, since one of these will burn :in\ living tissue which it touches. It is a good plan always to glance at the solution before using it, to be certain that none of these globules arc present. If cold water is used to make the solution 1 part of rinc and 1 part of alcohol arc added to assist in dissolving the carbolic acid.
DISINFECTANT SOLUTIONS
8J
Corrosive Sublimate (HgCl,).
Bichloride of nil rcury is soluble in 16 parts of cold water, and ranks next to carbolic acid as a disinfectant, being used in solutions varying in strength from I : 500 to 1 : 1 50,000, but for destroying germs the strength used should not be less than I :iooo. It is a powerful irritant poison, and must be used With great care. The 1 :iooo and 1 :20oo solutions are most often employed. Where it is employed for washing out any of the euvitic- <>f the body weaker solutions are used (1:5000 to 1:10,000). It is now but rarely employed for this purpose, as the drug is readily absorbed, and has frequently been known to produce symptoms of poisoning, These symptoms are quite definite, and should be carefully watched for by the As a disinfectant for clothing it is objection- able, because it stains white materials yellow, nor can it be used to disinfect instruments or anything made of metal, as it corrodes them.
To make a l :i,ooo solution I gramme (about 15J4 grs.) of the powder is dissolved in 1 litre (about 2 pints) of water; weaker solutions can be prepared from this. Any solution requires to be made fresh fre- quently, as it decomposes and loses its disinfectant qualities if allowed to stand a long time. An amount of common snlt added to the bichloride will hasten its solution and prevent decomposition.
Milk of Lime.
Milk of lime is considered especially valuable to render innocuous the evacuations from the bowels, but it should be freshly made, otherwise it is useless. Equal parts should be thoroughly stirred up with the
84
NUKSLS'G
contents of the bed-pan, which must then be allowed to stand for not less than an hour. This is the best method of disinfecting typhoid stools. The milk of lime is made by adding I part of slaked lime to 4 parts of water.
Chloride of Limb.
Chloride of lime (chlorinated lime) is perhaps a luiicr disinfectant than milk of lime, but it is not al- ways reliable, as it may be stale, and is objectionaliK owing to its disagreeable odor. In fact the so-called "hospital odor" can be directly traced to a free use of this disinfectant. From this substance in the presence of air and moisture is set free nascent chlorine, a most powerful reducing agent and highly inimical to living organisms.
Boric Aero.
This drug is classed among disinfectants. It is true that its disinfectant properties are not very marked, but it possesses the additional advantage of being non- irritating. It is used in the 5 per cent, or saturated solution and in solutions of weaker strength for its cleansing effects in the washing out of cavities, for superficial wounds, or for irrigating the bladder. The saturated solution is made by adding 1 part by weight of the acid to 19 parts of water. In making the solu- lion it is much better to use the drug in the crystal- lized rather than in the powdered form. Boric acid crystals arc very light, the measured quantity being short of the required quantity by weight. A saturated solution is best made by putting an excess of the crys- tals in a filter and pouring the quantity of boiling water
DtsrxFECTAtrrs
85
over them slowly until dissolved. The excess crystals arc precipitated when the solution cools.
Formaldehyde.
Formalin, the commercial name for a forty per cent, solution of formaldehyde gas, is a very useful disinfectant for clothing, rooms, instruments, and vari- ous articles. It is applied most conveniently in the Of gas which is liberated from tablets contain- ing it (paraform), which are exposed to the action of heat obtained from specially constructed lamps. In this way it is applicable to the disinfection of empty sick-rooms and other closed cham- bers. Its irritating properties make it necessary to employ it only after the sick have been removed : the room is sealed and exposed to the' vapor for 24 hours; it must then be well aired before reoccupation. Am- monia water sprinkled about the room will remove the disagreeable odor. Tn the form of a solution (1 to 5 per cent.) formalin may be applied directly t" many infected objects.
Formaldehyde gas, when properly used, is now gen- erally considered very efficient when steam cannot be It also has the further advantage thai il docs not injure the objects to be sterilized. Its pene- trating properties, however, are still questioned.
Permanganate op Potassium and Oxalic Acid.
These are used in conjunction in freshly made sat- urated solutions to prepare the hands before operation and in some cases in the final preparation of the skin of operation patients. The exact germicidal value of these substances has not yet been definitely determined,
86 NURSING
Ml mtttl await the results of further bacteriological investigations before saying more about them.
Absolute Alcohol.
'I 'his is used for cleansing and disinfecting the skin previous to operation and for preserving catgut and other ligatures. It has but little germicidal power.
There arc a number of other preparations in use, such as crcolin, pyoktanin, salicylic acid, peroxide of hydrogen and lysol, but their comparative merits as disinfectants have not been fully established, and it is unnecessary to enter into detailed descriptions as to their preparation or application.
Normal Salt Solution.
Normal salt solution, so called because it is approx- imately of the same density as the blood-scrum, con- tains rV of i per cent, of sodium chloride. It is pre- pared according to the following formula :
1J Sodium chloride, 6 grammes (circa 5iw)j Distilled water, i/ooo cc. (circa Oij).
This is about equivalent to one tcaspoonful of table salt to a pint of water.
I:>: thoroughly with a glass rod, an J filter through filter paper into a sterilized flask or bottle of a capac- ity of about two liters; stopper the buttle with steril- ized common cotton, keeping the plug in place with a few turns of gauze bandage, which also prevents any accumulation of dust upon the lips of the bottle. The flask is then heated over a gas flame and the solu- tion allowed to boil, after which it is placed in the sterilizer to be steamed for half an hour. This pro-
DISTILLED WATER
8?
cess is repeated three times at intervals of twenty- four hours, the solution in the meantime being kept in a room at a temperature of about 300 C. The solu- tion is sterilized in this way because it has been found by experiment that after the first sterilization the spores are not destroyed ; the intervening twenty-four hours allow for the development of any spores which may have been present, so that they can be destl by die second sterilization ; the steaming on the third day kills any which may possibly still remain and the lohitioa is thus rendered completely sterile. Before the operation it is reheated and used at whatever tem- iture is desired.
idea being employed for subcutaneous injections, salt solution 1- need surgically for irrigation or for sponging exposed tissues, to keep ready for use rubber S, which arc to be employed for covering skin- grafts and to wash out the abdominal cavity after ab- dominal operations. Besides its cleansing properties, it has been proved to act as a stimulant to the tissues and the red corpuscles are preserved in it, whereas they are destroyed by water. Sterile salt solution should always be kept in stock ready for immediate use in emergencies. All solutions kept on hand constantly must be changed frequently.
Distilled Watkr.
Distilled water, when used in large quantities, can be most readily obtained from a boiler room, as it is easily made by turning on the iteaffl in the boiler and allowing it to condense. It is frequently used now in- stead of disinfectant tolutfODJ for covering instruments,
88
A'VffSfAfG
for sponging! and, instead of boiled plain water, for preparing salt solution.
The principal point to remember in disinfecting with solutions is that the disinfectant must come in contact with or be diffused through the substance for a prescribed length of time in order that it may be effectual in destroying the bacteria; a mere washing with the solution or pouring it over the object will be of no use.
THE METRIC SYSTEM.
The adoption of the metric system as the standard method of weight and measure is the natural result of the influence of foreign scientific education. In Europe, except perhaps in England, it is universally used, chiefly on account of the greater convenience winch it affords. It is being more and more em- ployed by the public, and is now exclusively used in the exact sciences. As many modern hospitals and physicians employ the metric system constantly, it is absolutely necessary that the nurse become familiar with it.
The standard taken first was the meter (39.39 inches) — a standard which can be recovered at any hould the present rule be lost, since it approxi- mately represents the ten-millionth part of a quadrant of the earth*! meridian. All the other terms in the system are derived in some way from the meter, which is taken as the unit.
Any subdivision of the meter is expressed by a Latin prefix ; on the other hand, when it is increased or multiplied. Greek prefixes al"C used. The former are deci- (from decern, ten), centi- (from centum, a hun-
THE M ETHIC SYSTEM
89
drcd), and milli- (from mille, a thousand) ; the latter arc deca- (from deka. ten), hecto- (from hekaton, one hundred), and kilo- (from chilioi or chilia, a thousand). The two arrangements, then, would be as follows:
Meter. Decreasing.
dteimettr =one-tenth. .1, or 1-10 of a meter,
centimeter ^:onc-hiindrcrltli, .01, or j-ioo of a meter.
millimeter =one-tliousaiidih, .001, or 1-1000 of a meter
Meter.
dekameter hectometer
kilometer
Increasing.
=len meters.
= hundrcd nieters.
^thousand meters.
Thus, one decimeter, ten centimeters, or one hun- dred millimeters arc equivalent expressions. The eulir of a centimeter is called a cubic centimeter, and is written i cc.
The standard of capacity is based upon the stan- dard of length, and is represented by the liter, which is equal to 1,000 cc. The weight of 1 cc. of distilled water at 40 C. is called I gramme, and in this way we get the unit <>f weight.
Thus we have the meter as the unit of length, the gramme as the unit of weight, the liter as the unit of capacity: and the same prefixes as were used for the meter denote their division or multiplication.
In ilic i-.i-vc r.f tin- liter the divi.Mons arc rarely spoken of as deciliter, centiliter, or milliliter, but for conven-
the cubic centimeter, the equivalent of the mil- liter, is used entirely; e.g., wc say 100 cc. instead Of 1 deciliter, or locc. rather than t centiliter, or I cc. rather (ban 1 milliliter.
9°
AY'/,-
The relation of the metric system to the weights and measures of'thc tables in common use are as fol- lows:
I meter = 39J9 inches. 2$ millimeter* = I m. !>
I liter = 33.81 Raid minces, or about J pint*.
J9J7 ec. = 1 Bold o"!
4 ce. =1 fluid drachm, or 5 cc.= 1 tea^poogful.
I cc =>S minimi, approximately.
I gramme = iS'/i grains, approximately.
1 grain = .065 of a gramme.
The term micro-millimeter is used in measttring mi- croscopical distances, and means tV of a millimeter ; it is indicated by the Greek letter t> ; thus a red hlood- corpuscle is said to be from 6 to 9 m in diameter.
THE PREPARATION OP SOLUTIONS.
In the preparation of solutions the greater conven- ience of the metric system over the old system will be made at once obvious by giving a few illustrations, since with it the use of vulgar fractions is entirely done away with.
Solutions of carbolic aciil and corrosive sublimate arc the ones ordinarily used in hospitals, and for the sake of convenience strong standard solutions arc al- kept i" Stock, ad Weaker ones made from these, when required for use. by diluting with the neci ssary amount of water. It will be found very useful to adopt as a standard -.trong solution of each of these, one which contains in 30 parts 1 part by weight of the drug. We speak of these as "1:20 solutions." The weaker solutions are made most easily by simple dill) tion, although of course, if une wishes, they can be
PR UPA RATION OP SOLUTIONS
9'
prepared by dissolving the antiseptic substance in water in the desired proportion.
When using solutions of standard strength (1:20) it is important to remember that 20 cc. of the solution correspond (O 1 granule of the antiseptic substance. We sai'I above that 1 gramme was the name given to the weight of I cc. of water. Thus, to make a solu- tion of the strength of 1 :iooo we must have 1 gramme of the chemical in 1000 cc. or 1 litre of the finished solution; this Is readily obtained by mixing 20 CC. of our standard solution with 980 cc. of water. The whole liter thus contains 20 cc. of the standard solu- tion, i.e., I gramme of the original substance in 1000 cc. and the solution is thus rightly named "1:1000."
For making bichloride solutions the metric system i* almost exclusively used. Rememberin;; thai one li- ter equals 1000 cc, and taking a 1 :20 solution as the basis for making the weaker one, we take
20 cc. and add water to make t liter of a 1:1000 solution
10
5 4
a 1
1 .•.*»> 1 -.4000 1:5000 1:10,000 caouooQ
To make more dilute solutions than these it is more convenient 10 Mart with a I : IOOO solution and dilute this. For instance, to prepare I liter for irrigation of irengtli of 1 :ioo,ooo one has simply to dilute the i:tooo solution 100 times; thus, 100 cc. of the new Solution must contain i CC of the 1:1000 solution; IOOO cc. (1 liter) would therefore require 10 cc. of the I :iOO0 solution : so by taking 10 cc. of the 1 :iooo so- lution and adding enough water to it to make up a
92
NURSING
liter, the new solution is made. To make a solution of the strength of t : 150.000 wc must have I cc. of the 1 :iooo solution in 150 cc of the new solution. Now. 150 cc. is contained 6.6 times in 1000 cc, so that for 1 liter of the new solution we must have 6,6 cc of the 1 :iooo solution. Similarly, solutions of any strength can be made.
The old method of using apothecaries' weight still prevails in making up the various strengths of some solutions, particularly those of carbolic acid. To make a 1 :20 solution of carbolic acid one has only to add 1 part of the acid to 19 parts of water ; as a rule, how- ever, not less than a quart is made at one time.
Thus, let it be required to make 1 quart of a 1 .20 solution of carbolic acid. NTow, 1 liquid quart = 32 ounces. If in 20 ounces of the solution 1 ounce of carbolic acid is contained, then in 1 ounce or part of the solution there will be only iV of an ounce of acid, and in 1 quart or 32 ounces of the solution there must be 32 time* iV of an ounce — i.e., 32 X iV = H = 1.6 ounces, or I ounce and A\ drachms. Then, tak- ing this amount of acid, sufficient water is added to make the whole up to 32 ounces or 1 quart, and the required solution is obtained.
The weaker solutions arc usually made in strengths of 1 :30, 1 140, 1 150, 1 :6b, 1 :8o, 1 :ioo, and of course to make up any of these strengths from the pure car- bolic acid one proceeds in a precisely similar manner.
For instance, to know how much pure carbolic is needed to make any amount of a 1 :4c solution, one calculates the amount of acid that is equal to one- fortieth of the whole solution.
Example: Let it be required to make a quart of 1 140
PNEPAKATIOX OP 'As
93
solution of carbolic acid. Now. i quart = j,2 ounces. The amount of acid required is of course A of 32 ounces — H or J of an ounce of carbolic acid—/.*, a little less than 6} drachms.
We so frequently hear the term "per cent." in con- nection with the different solutions that to avoid all possibility » ■ f" error we will discuss its meaning in de- tail. The term is best explained by an example. Thus, by a 3 per cent, solution of cafbollC acid we mean 0M of which too parts contain 3 parts of the acid. Thus. if we have a mixture containing 3 minims of carbolic add and 97 minims of water, we have a 3 per cent, aqueous solution of carbolic acid. A 1 :ao solution of carbolic acid ( 1 part ■ arbolic acid in every 20 parts of the solution) will be a five per cent solution. For.
In 20 parts of solution we have 1 part carbolic acid.
1 1 1 part of solution wc have 1-20 part carbolic acid.
In 100 parts of solution we have too times i-ao (=5) part*
carbolic acid).
So that a 1:20 solution is a 5 per cent solution.
Similarly one can reckon the percentage in any other solution ; for instance, in a 1 140 solution.
40 psrts contain i part of carbolic acid.
rt contains 1-40 part of carbolic acid. 100 part-; contain* ioox 1-40 (=2i|j) parts carbolic acid. So that a 1:40 solution is a 3'A per cent, jolui
Since the weight of a given volume of carbolic acid differs but slightly from that of the satm volume of water, these solutions may be made np with sufficient accuracy by measurement instead of weight.
Bomc ACID SOLUTION. For a saturated solution use crystals 5v to water Oi.
94
NVKSIX6
POTASSIUM PERMANGANATE SOLUTION.
For a saturated solution (1:16) use crystals 5> to water Oj.
For a i% solution take of the saturated solution $''** to water Oj.
Care and Disinfection of an Infected Room. — In a hospital there should of course be no superfluous fur- niture or articles to remove at the beginning of the dis- ease, but if in private rooms there are such, they arc to be taken out at once: carpets, upholstered furniture, hangings and bric-a-brac, or any personal clothing, the color of which may be destroyed by the action of steam, must not be allowed to remain. Such a room should he in as isolated a portion of the house as pos- sible and correspond in the main to the sick-room al- ready described. The daily care of such a room consists in wiping off tlie furniture with a damp cloth and sweeping the floor with a broom cov- ered with a damp cloth wrung out of a 1 :20 carbolic acid solution; besides this the floor must be rubbed thoroughly with a damp cloth every second or third day. If the disease be contagious, further precautions may be taken by hanging up a damp sheet, kept moist, in the line of air currents. All cloths that are used daily should be washed in hot soapsuds and. when not in me, left to Mill in ■ i 30 cartiolic-acid solution. Af- ter the patient has recovered from an infectious disease Ik- should receive a hot soap-and-water tub or sponge bath ( including a thorough washing of the hair and irrigation of the cars) followed by a thorough spong- ing with carb<>lic-acid or bichloride solution. The fin- ger-nails and toe-nails arc cut close and cleansed under- neath. A nasal douche is given and the mouth washed OUt with listcrinc or a saturated solution of boric acid.
Disi.vFEcrro.v ot room
95
after which the patient is wrapped in clean sheets or clothes and taken to another room. The next thing to do is to remove the clothing and bedding for steriliza- tion. Then begins the disinfection of the room. The mattress is brushed off. wrapped in a damp sheet wrung out of a 20 per cent, solution of carbolic acid, and sent to the sterilizer. The clothes are steamed and then sent to the laundry. Where there is no sterilizer, the bedding must be soaked in a 1 :20 solution of carbol- ic acid and afterward boiled and the mattresses ripped apart and boiled or else burned.
The care of the infected room should then be as follows: All articles are to be left in the room and arranged so as to expose all or the greater part of them to the fumigating substance. To disinfect with formalin close the room tightly, scaling all cracks and openings with paste and paper. Place an alcohol lamp in a metal dlth in (h« center of the room. Put in a receptacle over the lamp three fluid ounces of I 40 per cent, solution of formaldehyde, moisten the air of the room, light the lamp and then close the room up tightly and leave it for twenty-four hours, until the dust has settled ; then enter very gently so as not to dis- turb the dust and wipe off everything in the room with a cloth wrung out of 1 :iooo bichloride solution. Treat all the woodwork, floors, furniture, and the bed- frame in this way, and use for the crevices about the bed-frame pure carbolic acid, applying it with a small brush. Wash down the walls with bichloride solution I :iooo. and then leave the windows wide open, so that the sunshine and air may i-ntri freely. In place of the solution, two formaldehyde candles may be used.
Where steam can be -ccurcd an excellent method. 1
96
A'Uksiag
whether formalin is used or not, is to fill the room with lis I i .mi, keeping up the supply till the moisture stands on the walls or floor: nearly all the bacteria will Ik di) the moist surfaces, and the walls and floor should be washed off with a disinfectant solution before they arc allowed to dry. The old method of fumigating with sulphur has been proven to be quite inadequate, as the funics exercise little if any destructive power on ba< M ria. If, however, sulphur is ordered, employ the same precautions and then light two sulphur candles. Or use the substance in bulk, 3 pounds to 1000 cubic feet, break in pieces and place in an earthen * 1 i - 1 1 set in a pu. Moisten the sulphur with alcohol, light and al- low it to burn from six to eight hours, keeping the room tightly closed.
Vomited matter, evacuations from the bowel* in typhoid fever, dysentery and cholera, should be re- ceived in a vessel, containing carbolic solution or milk of lime, which should he closely covered before being carried from the patient's bed through the room or ward. Four times the amount of the milk of UffiC ll then added, the whole being thoroughly stirred togeth- er; the vessel is then covered and allowed to stand for an hour.
In hospitals where there are many typhoid patients and tio conveniences foi treating the stools with the lime for that length of time, they should at least be mixed with lime, and when they are emptied down the hopper a good stream of very hot water should be al- low d to run into the vessel and down the pipes. This lure is at lust a poor substitute and one that should be used only under the stress of Special circum- s. In the Country, where these conveniences arc
VtSWSAl. Ut> EXCHBTA
97
still less frequently found, the stools may be mixed with bran or sawdust and burned.
In regard to the sputum of patients several points must be carefully considered, viz., the receptacle in which it is deposited, the manner in which it is kept, and the final disposition of it. Especial precautions should be observed with the sputum from tuberculous lungs, the organism that causes this disease being wry virulent and infectious and retaining its infective properties for a long time. Direct contact with tuber- culous sputum is one of the greatest sources of infec- tion : besides, if the expectorated material be allowed to dry and become scattered broadcast, the bacilli may be absorbed with the inspired air into the lungs, and lie quiescent for months until favorable conditions de- velop, under which the germs can multiply and repro- duce the dread disease. Therefore, every precaution should be taken to destroy the bacilli contained in the expectorated matter. The sputum cups used for such patients should be cither of china or paper, so that they may be boiled or burned, ami made simply, with no crevices in which particles of sputum can lodge. The cup should be kept covered and the sputum moist, so that none of it, becoming dry, may escape into the air of the room. The vessel should be frequently cleansed, fend before the contents arc thrown away the germs shouM lie destroyed by boiling the sputum in a 2 per cent, solution of carlxmatc of soda for one hour, or by inj: it to heat in a steam sterilizer for at least as long. An autoclave placed in the ward lavatory for the disinfection of stools, sputum and other excretions in a few seconds is now recommended. This, or a ves- sel in which the material can be boiled, is very necet-
98
XUKS/AG
sary. The paper cups with their contents should be burned.
In infectious diseases all discharges from the nose, mouth, bowels and bladder should be received in a china vessel containing carbolic-acid or milk of lime. In diphtheria the expectoration, nasal discharges and vomited matter should be received in paper napkins. and burned at once in the room or boiled before being taken from it. In scarlet fever, whooping-cough and measles the discharges from the throat and nose should be treated in the same manner.
Two sets of cups should be kept, and boiled in the soda solution each time before being used again. AH v -.■!•.. tuba Of COpa that lit um-.| for the mouth in diphtheria, syphilis or cancer should be kept in a 1 :4c carbolic acid solution and boiled before being uaed by another patient. Bed-pans used in cases of cancer, in dysentery, typhoid fever, or other infectious diseases, arc to be soaked in a 1 :20 carbolic acid solu- tion, and boiled before again coming into general use. Sheets and clothing stained with typhoid or dysenteric discharges must be washed out at once, or soaked in a disinfectant solution and steamed before being sent to the laundry. The bedding and clothing from any case of infectious or malignant disease should always Ik- put to soak at once in a 1 :20 carbolic acid solution, or else steamed or boiled before being brought again into general use.
Strict precautions are needed for the urine in certain infectious diseases. In typhoid fever, for instance, the urine is frequently contaminated with the specific bad! It of the disease. It is therefore necessary to disinfect this secretion, which can be done by adding milk of
ISOLATION AND QUARANTINE
99
lime or carbolic acid in the proper proportions. The urine may contain other virulent bacteria, as in blood poisoning and in cases of disease of the genito- urinary organs.
The act of coughing in diphtheria, pulmonary tuber- culosis, scarlet fever, etc., liberates infectious germs. These may be received on the person of the attendant, on i lie bedding or furniture, or remain temporarily suspended in the air. We are not yet fully informed of all the ways in which virulent germs are thrown off by the body, but besides those already mentioned there is reason to believe that they may appear in the sweat and in the secretion of the lactating breast in the fe- male. Too great attention cannot be given to disposing of all the secretions and excretions of persons suffering from infectious disorders.
Isolation and quarantine. — In order to prevent the spreading of disease or an epidemic, where a person has been exposed to a virulent contagious disease, such as small-pox, typhus, or scarlet fever, or where one develops symptoms that would indicate the onset of such a contagious disease, steps should at once be taken to ensure isolation until the symptoms either develop or the individual is perfectly well after the time rtfCflHrjf for incubation has passed. Where such a disease has developed not only the person infected but all others exposed should be placed in quarantine, the entire house and its occupants isolated, and no personal com- munication allowed" with people outside during the progress of the disease. With many infectious dis- eases, however, it is possible to so completely isolate the patient and attendants that the rest of the family
lOO
NURSING
are not exposed. In the carrying out of such details much depends upon the nurse.
A full description of the methods of disinfection to be employed under different circumstances will be found in Dr. G. H. F. Nuttall's manual entided "Hy- gienic Measures in Relation to Infectious Diseases," to which the student is referred.
CHAPTER V.
Beds.— Bed-Ma kinc for Bed Patients; tor Convalescents.— To Prepare a Bf.p for an Operation Patient.— I-Vm hki Beds.— Mechanical Appliance* rOR the Relief or Bed Patients.— Liktinu and Movinc.
The regulation bedstead for hospital purposes has a metal frame, iron or brass being usually em- ployed for this puq>ose. In private houses wooden bedsteads are still often found, but they are apt to be cumbersome and arc not so easy to keep clean. Nor can they be so readily and thoroughly sterilized. Any family would do well to have an iron bedstead on hand, and in any case where there is to be a prolonged illness in the house one should be purchased. Ten or twelve dollars will cover the expense. There arc many varieties of the iron-frame bed, and just what selection is the most desirable is often puzzling to a buyer who has not had the actual experience of testing the merits or imperfections of the different kinds. A nurse who works over them daily ought to be a fair judge of what is required in the way of a bed for the sick. Four things should be taken into consideration in making a choice: viz., height, weight, durability, and simplic- ity. The height must be greater than that necessary for ordinary beds, not only because the continuous bending over a low bed could not be endured by nurses for any length of time, but because for purposes of examination and treatment the doctors must have a bed which will not necessitate much stooping. To the
101
IOC
XUXS/:VG
patient this point is really immaterial, for a footstool can lie easily supplied for stepping into or out of bed, or if a patient thinks that he is more comfortable when ■sitting on the side of the bed. a lounge may he placed alongside for the feet to rest upon. A single bed for a ward and a three-quarter bed for a private room will answer every purpose. It is rare for even the largest person to find them uncomfortable, and too wide a bed would make it impossible for the nurse to do her work with any comfort either to herself or to her pa- tient.
The bed should be of medium weight. Great, beavj , clumsy iron beds arc out of place, as it is im- possible to move them without extra help and they arc apt to become wrenched during the process, and be- sides are not likely to last any longer than lighter ones. An iron frame should last for years without need of repairs, if well put together and provided with a firm double woven-wire mattress. It should be made with the utmost simplicity, for the sake of cleanliness, rod should have absolutely no wood about it The corners and crevices, where vermin or dust can lodge without being easily removed, should be as few in number as possible. There should be a low iron bar at the foot as well as at the head to prevent the mattress from slipping. A little more finish can be given to the bed- stead by the addition of a brass rod across the foot and head and of brass knobs on the posts. Painting or enameling with white adds much to the appearance. The length of such a bed should be 6 feet 6 inches, die width 37 inches, and the height from 24 to 26 inches. As its position has frequently to be changed, it should be mounted on rubber casters. The only objection tq
BEDS AS'D MATTRESSES
IOJ
these is that they make it hard to keep the bed straight, as one or both ends arc readily moved by even a slight touch. It is therefore well to do without casters if enough men or a special apparatus, now commonly used in hospitals, can be procured at short notice to lift and carry any bed which has to be moved, for then the floors are not scratched, since the beds remain firm in their places. Every bed should be placed in MCh I position as to be freely accessible from all sides. The best form of mattress for general use is one made of prepared horse-hair, weighing from 22 to 25 pounds. A fur being vacated by a patient, the mattress should be disinfected in a steam sterilizer and exposed for a short time to the sunshine and air before being used again. At intervals of twelve or fifteen months it should be taken apart, the ticking washed, and the hair renovated and made up afresh. In some hospitals two layers of army blankets are used over the wire mattress, but they do not make so comfortable a bed. Straw mattresses are so cheap that they can be renewed for each patient, but unless carefully made up they are i;.r 1.: In' lumpy and extreme!} mii'.imfoitaMi-. FttthCf beds are met with only in private practice, and a nurse's ingenuity will have to be exercised to effect a change, since anyone who sleeps upon feathers in the present age is very apt to be "set" in her ways. The idea of making the mattress in three parts is not a good one, for if patients arc at all restless the divisions slip apart, and. although the middle portion of the mattress can be changed without interfering with the other two, it is not much easier to do this than to put on an entirely fresh mattress or to lift the patient to another bed. Each bed should be supplied with two pillow*.
104
NO/tSWG
one of hair and one of feathers. Frequently only one is required, and in fever cases or where there is much perspiration this should be of hair and should be pro- tected with a case made of rubber sheeting put on un- der the regular cotton case. Except in unusual cases the mattress is turned daily.
The coverings should be light but warm, consisting of an upper and a lower sheet, each sH yards in length, and a draw sheet 2J4 yards long and 2 yards wide. These should be made of white bleached cotton, as linen is more apt to be chilly and damp. Some light form of white cotton spread should be used on the outside, dimity being the most suitable material. In hospitals, at any rate, the usual heavy white counter- panes should be no longer tolerated. A patient is often uncomfortable with a counterpane on, though he cannot discover the cause of his discomfort, and with operation cases and fever patients they should never be used, a clean white sheet being preferable. Counter- panes also interfere with the ventilation of the bed, and, though it is true that they make a ward look well, the patient's welfare should be the first consideration.
A nurse should be familiar with the best method of making a bed for a bed patient and with the manner of changing the sheets, pillows, and the patient's linen, so that the bed may always be kept in good condition. Only a great deal of practice will make her quick and deft in the performance of this work. To make a bed for a patient who must be in it for any length of time, a mattress should l>c selected that is smooth and even. not worn to a hollow in the centre : the lower sheet is put on first, and should be long enough to allow the ends to be well tucked in. first at the top and bot-
BED MA K I. KG
.05
torn, and then at the sides ; next a draw sheet of rubber cloth, 32 inches long and 45 inches wide, is put on, the upper edge reaching to the edge of the pillow, and the lower coming down well below the place where the patient's hips will rest. The cotton draw-sheet (doub- led) should cover this entirely ami he tucked in under the sides; in order that it may he perfectly free from wrinkles, it can be kept in place by being fastened with a safety pin at each of the four comers to the under part of the mattress ; the two hemmed ends should be at the lower end. as there should never Ik- a seam under the patient's back. The upper sheet and blanket come next, and lastly the counterpane. The upper edge of the blanket should be protected from soiling by being folded in the counterpane, at the top, 0 i| and the upper shed ; to keep the coverlet clean a margin of about nin< inches of the upper sheet is folded back over it. In tucking in these covers at the bottom one should be careful not to draw them too tightly over the patient's toes ; they must be loose enough to allow the feet to be moved about with com- fort. As a matter of routine, bed-patients' beds should be made up thoroughly night and morning and fresh ened at mid-day. But it is to be remembered that, day or night, an occasional smoothing and tucking in tightly of the under sheet, a shaking up and turning of the pillow and a straightening of the top sheet and coven are always ;• relief and refreshment to restless and feverish patients. A bed that always looks fresh and well cared for affords objective evidence of good nursing.
The changing of linen should be managed with as little fatigue and discomfort to the patient as possible.
1 06 NURSiXG
Unless the patient is very ill one person can do this easily. Only the Upper sheet or a single blanket is to be left over him. The lower sheet and draw-sheet to be removed arc loosened at the top, bottom and at both sides; on one side they are then folded along their whole length as flatly as possible until they are close up to the patient. The fresh ones should be then fold- ed lengthwise, alternately backward and forward, for half their width, and placed on the side of the bed frnm which the soiled ones have been removed, and the loose halves tucked in at the side. The nurse then moves to the opposite side of the bed and turns the patient on his side with his face toward her; she can support him in this position with one hand while she tucks the sheets to be removed as closely and smoothly as possible up to his back, their place being taken by the fresh ones, which are made to follow them closely. Using both hands, the nurse now gently turns the pa- tient toward the side away from her ; the soiled sheets and the folds of the clean ones are drawn through, the former being taken away and the latter smoothed down and tucked in their place, care being taken not to leave the smallest wrinkle. Patients can often as- sist in this changing by means of a crane suspended above the bed, by which they can raise themselves more or less ; but if a patient is quite helpless and very heavy it is best to have a second person to assist. In changing the upper covering the fresh sheet and blan- ket are spread over first, and the others arc then slipped away from underneath. It is quite unnecessary to expose any part of the patient in changing the entire bed-clothing. For con its it is unnecessary to
BED MAKING
IO7
have a rubber sheet 011 the l>ed, as its only object is to protect the mattress : when not needed for this purpose the patient is better without it, as it often causes per- spiration and may be uncomfortably warm, A con- valescent's bed should be well aired, and, no matter the time of the day .it which a patient gets up, for a half hour or more the bed should he left open. Two chairs should be used upon which to spread the clothes when taken off the bed ; one is not enough, as they arc apt to drag on the floor or become piled tip, so that no air can circulate through them. Each piece should be shaken separately before being laid loosely over the two chairs.
Care and economy in the changing of the bed-linen arc subjects upon which nurses need special instruc- tion. In most hospitals the bed is changed throughout after the dismissal of a patient. A convalescent's bed is changed twice a week, on stated days, a fresh upper sheet being employed and the used one being put in the place of the lower sheet. Fresh pillow-cases are provided twice a week. Coverlets, as a rule, need to be changed only once every two weeks. For bed- patients changes arc made as the necessity arises. A sheet that is not soiled may be hung out in the sun- shine and used again on the next day. In this way a change of sheets can be provided without extra ex- pense for laundry work.
In a hospital ward uniformity of appearance must be maintained in the beds, as it adds largely to the gen- eral neatness of the ward. It would never do to look down the wan! and sec some beds all hills and hollows, others with the spreads hanging farther down on one side than on the other, or with a corner hanging out in any direction ; or to see the pillows, some showing
io8
NUKS/XG
the ticking through the end of the slip, some lying flat, and others bolt upright. After all the angles have been tucked in and the bed has been made up neatly, a general mwoth appearance can be produced by running a flat stick, reaching across with some pressure, from the bottom to the top, before the pil- lOWl are put on. Waul patients are very fond of putting things away under the heads of mattresses; nothing whatever should he allowed to remain there, and their towels and bath-cloths should be neatly folded and hung on the imi;.: of the lied just liehind and below the pillows, where they will be well aired and dried if damp.
To prepare a bed for an operation patient the same process is gone through as described ifl making a bed for a bed-patient, with the exception that for extra warmth a single blanket it put on between the upper sheet and the patient. This, however, is dispensed with after the patient has reacted. The pillows should be removed on account of nausea, a towel being pinned in their place across the top of the mattress, so that the head may be low ; two other towels should be hung over the head of tin Led in case of vomiting after the hctic. and a small basin placed on the bedside table. Instead of being tucked in all around the bed- covering on one side should be folded back to the edge of the mattress, so that the bed may readily be thrown open the instant the patii ut appear--. Three large !»■ >t water cans should be filled, encased in their flannel bags, placed in the bed, and left there until the patient is put to bed after the operation. The nurse should be particular to see that these cans are really hot and that they do their work well, for by the time the pa-
FKACTUKE BEDS
ticnt is ready to be put in bed it should feel comfortably warm throughout. This beat assists the patient in re- : from whatever shock may have been sustained from the injury or from the anaesthetic and operation. But before tbe patient is put to bed the cans should be removed, otherwise there is constant danger of burning him; for during unconsciousness a leg or an inn in the trunk may be tossed about so that it is al- lowed to rest on a hot can and a severe burn may result This point is worthy of particular emphasis, for in spite of constant warnings and lessons, unfortun- ate patients arc still often burned through the care- lessness of nurses in forgetting this rule. Of course, when there is much shock after an injury or opera- tion and all the warmth and stimulus possible arc necessary to enable the patient to react, the hot cans or bags must be employed, but they should be carefully- placed at a safe distance and separated from him by a hlanb tl then the nurse should be on the watch
and frequently slip her hand inside the covering to as- sure herself that all is right.
Fracture beds. Patients with fractures of any kind must have their Ik<1s made with special reference to
their condition. The bed should be rendered firm and
ding. This is done by placing under the hair mattress a fraciurc-board. made of slats each i inch thick and 3 inches wide. This will be lighter and afford better ventilation than one made of a single perforated board. Felt or cotton mattresses may also be used in cases of fracture. A cheap but excellent fracture bed cm 1" bj packing straw very tightly
and evenly into a firmly thade tick and covering it over With a long heavy mackintosh, which should be pulled
MO
MKS/.VG
tightly down and securely tied to the iron hed-frame: in any case the long rubber sheet should be used and the bed is then made up with draw-sheet, etc.. in the ordinary way. IJeds are also prepared in this way for spinal curvatures and other orthopedic cases. If a patient has to remain in extension or must not be moved from the bed for a number of week*, the mack- intosh should be kept fresh and clean by an occasional washing, after which it should be rubbed thoroughly dry.
Very numerous and often very complicated are the appliances which have been contrived for the relief of bed patients, but the more simple designs generally serve the purpose best. Those chiefly in use are head- rests, pillows, pads, and cushions of various kinds. It is a red letter day for the patient when he is allowed to sit up in bed for the first time. He is raised at an easy angle and supported in this position by means of the head-rest and pillows; hair and feather pillows combined will accomplish the same result, and these are generally used in private houses; but more pillows are required than when the head-rest is used, and a comfortable position is maintained with more difficulty. These rests are of many kinds, but one of the best is that made with a simple wooden frame and a canvas support, which can be used with any kind of bed. A feather or hair pillow tucked in to sup- port the small of the back, another for the upper part of the back and shoulders, and a small circular air-cushion for the head laid against one of these rents will support the invalid in perfect comfort. An improved head-rest recently invented by Miss Nutting has a wooden frame with curved wooden cross-bars
i
MECIIAX1CAI. APriJAXCF.H
and a wing made of wood on cither side, which keeps the pillows in place. In lieu of anything better a straight-backed chair may be turned upside down, fastened in place, and pillows arranged on it. To
F>(. i.
Ill
enable a patient to lift himself or change his position in bed, a crane will be found very convenient : this may consist simply of three bars of iron in the shape of a triangle fastened to the wall above the bed. or of a single rod fastened to the bed, to which a strap
t II
NUffSLS'G
or handle is attached which hangs down within easy reach of tlx? patient (Sec Fig. i). This apparatus should be supplied with a hinge, so that the crane is movable to the right and left, ami can thus be pushed aside when not needed. Beds furnished with patent adjustments arc rarely as comfortable as those which are less pretentious.
A head-rest is also a great comfort and support to patients suffering from shortness of breath arising from heart disease, asthma, or any other complaint which makes the upright position imperative. In connection with the bead-rest the cylindrical cushion is used for patients who are inclined to slip down in bed. The covering of this is made of stout ticking 21 India long and 8 inches thick. It has rounded ends and is Muffed In inly with horse-hair and covered with cot- ton slips made to fit. To the ends of this pillow, which is slipped under the patient's knees, are fastened broad bandages which are carried up the sides to the top of the bed and tied to the iron rods tightly enough to keep the pillow in position under the patient, and so prevent him from slipping down. There should he a number of such pillows supplied to gynaecological and obstetrical wards, as they often give the greatest relief to patients after abdominal operations. When placed under the patient, just so that the knees rest upon them, they act by relieving the tension of the muscles of the abdomen and hack; or when placed at the foot of the bed, where the patient can press her feet against them, they accomplish the same purpose. After abdominal operations, in place of the ordinary pillow, which is too high if the patient is nauseated, a small air-cushion or a feather pillow not ton soft,
1
MECHANICAL APPLIANCES
»'J
and about 13 inches long and 10 inches wide, should
be used for the head to rest Upon during the first forty- eight hours. In the case of very weak patients, or those whom it is necessary to turn frequently from side to side, support should be given to the back by plac- ing a pillow closely against it. Very often pressure along the spine can be relieved by partially slipping a hair pillow under the patient from cither side, thus raising the middle portion of the back so that it does not touch the bed.
When a patient is confined to bed the portions of the body most exposed to pressure should be guarded against bed-sores. The most common sites are the lower part of the back, the hips, the shoulder-blades, the elbows, the tips of the ears, the back of the neck, and the inner surfaces of the knees, the heels, and the ankles. On the slightest indication of redness, even before any complaint on the part of the patient of a burning or stinging sensation in any of these places, in addition to employing the other usual pre- ventive methods of treatment, the nurse should take care to remove all pressure from the parts threalemd This may be done by means of* cushions, which may be made of various shapes to suit the part to be pro- tected. Besides the air-bed and the water-bed, there are on the market a number of rubber appliances in the way of cushions, among which we may mention the air-cushion and water-cushion, which arc made squarc-sha])cd for the head and shoulders and circular for the back. For protecting the heels, ankles and inner sides of the knees or the back of the head, a circular pad of a suitable size can be made of ordinary hatting. The cotton is held firmly in place by
M4
XUHS/.VG
u jjaiuc lwndagc passed around it several times, a hole
lift in t In- center which comes directly under the
; i nil while the unrounding parts rest on the
ii. n ll'ir ptdl .»re inexpensive and may be re-
ii .1 I ip..|i .1 mi I v. l'or a snail spot on the back, side,
v purpose (See Fig. 2).
I hlRM of a bandage will hold one in place.
in tn Ik' protected. Where a rubber
1 «. *.
Hoi Cuiuiok,
ring i» not available fbr the back in a case of bed-sorr,
v fOOd substitute may be found in a circular
n made either of rubber cloth or of ■ double
nlcd muslin stuffed with horse-hair. This
in In .1 .li< 1 1, and by having two they may be changed
Mini KPlCBfH fresh and free from odor.
1 11 In. 11 f any niie can be made of bran or fine MWdWl liny are soft and comfortable, and can be
I and rni .il at little COft In making tliem
I I 11 Id In- taken not to fill the case too full ■di and air -btds are sometimes ordered for
MECHANICAL APPLIANCE*
patients who are predisposed to bed-sores, or for those who already have very bad ones, or who are in a per petual state of moisture, a condition which is also likely to destroy a hair mattress. For paralytics they are indispensable. In getting a water-bed ready for use, the wire springs of the bed-frame are covered with a long heavy mackintosh, and upon this is placed the water-bed ready to be filled. Care must be taken to have it laid on the bed-frame exactly as it is to remain, for when once filled with water, it is too heavy to be readjusted. The end with the opening through which the water is to be poured should come at the foot of the bed. The filling is done by means of a hose, or, if this is difficult to manage, the water may be poured in from a large pitcher through a funnel. The tempera- ture of the water should be carefully tested, and should not be less than too0 P. This will allow for some slight cooling when it comes in contact with the rub- ber of the bed: if the patient has been ill long and is in a weak condition, he should in no case be put upon it if the bed temperature is less than 980 F. To pre- vent the patient from rolling off the bed when lille 1. a wooden frame should be placed around it, both sides of which should be bevelled or else the sharp edges of the boards should be padded. An air-bed is ar- ranged in a similar manner, except that the air is introduced with a force-pump and attention to the temperature is unnecessary. Rubber beds should be washed off and disinfected from time to time. No pins must be used in these cases, because a pin-pm-l: might cause the bed to collapse and render it useless ; this is an important point, as these beds arc very expensive.
It*
v4v«a£r W a *upi a which Ihc bed covcr-
«K*«t* umkV tSM Of WOOads, fractures and
im vttott C**c« w« UrMdl eness or pain is caused
titty arv made of iron or wood and are
v«»<V« vbK«<y COkt in shape. In «-ni« r
•o readily made from the halves of
lifting and moving sick people
tl i»f practice, and a beginner should not
like for the sick. She
.►vmld «i "i experienced nurse and thus
I>in.|»'i methods. It seems a difficult mat-
IHIrMI to understand that, in moving
. in thing* h«T position, it is of the utmost
»i|i;.ntt the patient: if this be properly
' person can be moved with little
without hurting her at all. Occasion-
inil is made that a nun* has injured
ffd henelf in some way in moving
i >\ill generally be because she has
In (In lifting properly. To move a heavy or
I I" | " n in bed the nur>e should put her
bliquely under the patient"s back.
! well down under the back, the
ng in the hollow of her own;
|| next put over and slipped well undei
i other shoulder. The upper half of the
i u iiiiw lifted gently and evenly and placed in the
• i lln I" I 'In light hand being now slipped
part of the back and the left just
I hips, the other half is moved over. To
he brad of the bed the right hand is
I vsrll undei the lack, the heavy part of the
MFC HA MCA I. ATI 7. IASCBS
"7
shoulder being supported with the upper part of the irn mm! shoulder, and the left hand being placed below the hips: one then lifts gently and firmly. In doing this the greatest weight is thrown upon the right arm and shoulder. The patient can sometimes render some assistance by clasping the hands around tin- nurse's neck In the same way support should be given with the left arm when raising patient-, to readjust or arrange pillows, the head being allowed to rest against the nurse's shoulder while the back is sup- ported with the hand, the other being used for putting the pillows in place. The head and shoulders are then placed back against the pillows with an easy, gentle motion. It is the height of awkwardness to pull or drag a sick person about the bed when working over her. The ideal way to change a bed patient is to have two single beds of the same height, one for the day and one for the night, each being provided with its own set of blankets, sheets, etc. The patient may be transferred from one to the other by placing the beds close together and drawing the mattress with the patient on it a short distance over that on the other bed ; the occupant may then be transferred to the second bed by pulling on the sheet upon which she is lying. If there be a second nurse to assist, one can take the sheet at the head and the other at the foot of the bed, and, both lifting carefully and at the same moment, the patient can be placed in the middle of the adjoining bed without the least jar, after which the sheet may be slipped out from under her. After abdominal operations this method is quite safe, but, of course, with some surgical cases moving is altogether out of the question. If two such beds are
Ii8
XUftS/NG
not procurable, as is often the case, a lounge may be wheeled u]i dose to the bed. the patient, together with the sheet, lifted upon it. and left there until the bed has been aired and changed. Another excellent way is to have two mattresses with one bed: one person may draw away the mattress on which the patient is until it is half way off the bed; then the second mat- tress is put on close to the other, and the patient drawn In ihe sheet over upon it. It will afterward be easy to slide it the rest of the way on the bed. If the patient is to be carried to a lounge, this should be placed at the
Fit. a.
Roam Photictivi Pad.
foot of the bed i with its head towards the foot of the bed) in such a position that the carrier need take Old) two or three steps from the bedside: he thus has to do no turning, and can lower the patient gently. Similarly, when the patient is to be transferred to it, the invalid chair must always be placed with its back inwards the bed. When OOC is carrying a patient, it U !c It to straighten one's self up and allow the weight to fall upon the chest and front part of the body, since strain on the lower part of the back is thus prevented. A small bed-side table, of the same height as the
MECHANICAL APPLIANCES
l!9
bed, is often a comfort to a bed patient suffering from heart disease or whose arms need extra support.
For the purpose of saving the mattress and bed- linen, and of obviating the necessity of disturbing the patient at too frequent intervals, a much less expensive protection is afforded by the rubber protective pad (Sec Fig. 3). It consists of a flat circular piece of rubber, 29 inches in diameter, around the edges of which is attached a hollow rim, which when inflated measures 6ve indies in diameter. A square pad of gauze or old linen may be spread over it before placing the rubber pad under the patient With this pad it is possible to keep a bed perfectly dry and comfortable in the worst forms of involuntary evacuations; its use will effect a great saving of the patient's strength, of time and of laundry work. Before being replaced it should be washed off, dried, and fresh gauze should be spread over it
CHAPTER VI.
Care of New Patents.— Treatment. — What to Observe.— Reporting to the Physician. — Cake of the Bed Pa- tients.— Frequency of Bathing.— Care of the Teeth and Mouth. — The Prevention and Treatment of Bed- sores.— Care of Convalescents.
The first attention a. nurse gives to a patient will de- pend entirely upon the condition he is in when placed under her care or when brought into the ward. He ma\ be ahle I" walk. M pOttibly just strong enough to he moved if seated in a whccl-ch3ir, or, on Uie other hand, he may be so helpless than he has to be carried, and that, too, in the gentlest manner possible. A stretcher will be found most convenient for moving such patients. This should be made of stout canvas, 6 feet fi inches in length and 2 feet wide, with hems on either side wide enough to allow two hardwood poles, 7 feet long and 2 inches in diameter, to be pushed through them ; the poles are kept in place by means of a movable cross-bar at each end, which prevents the ides from folding together.
In every hospital with free wards there should be tWO receiving-rooms — one for men, the other for wo- men. Each should be provided with bath-tubs and all requirements for giving the first bath, and in addition there should be kept here a stock of wrappers, night- gowns, stockings and slippers, gray blankets, and a bed. A patient who is able to walk or to be moved in a I chair should be taken directly to this room, and 120
A NEW I'AT/ENT
lit
at once 1,-iviii tin- first hath; a nightgown, wrapper and slippers arc then put on, and the patient with a blanket wrapped around him i> sent into the ward. Except in a case of emergency no patient should be taken to a free ward with his own clothes on: these should be removed and he should have at least one bath, cither in bed or in the tub. before he comes near other patients. His clothing should be inspected and ■a li.vt taken, after which all articles are sent to the dis- infecting oven in a covered metal box. After steriliza- tion they are sent to the laundry to be washed, or if clean enough arc hung up carefully in the patients' clothes-room — a large room well ventilated and set apart for this purpose. Sometimes, however, a patient is admitted in an extremely critical condition : then no foil ihootd be loit, and the physician orders such a patient to the ward at once. In anticipation of such cases, one bed should be kept freshly made up, so as to be ready at a moment's notice. If the patient is very dirty as well as very ill, the upper coverings should be thrown back and a long rubber sheet spread over the bed ; a bath blanket is thrown over this, and th( patie&f ll lifted into bed. A second bath blanket is now thrown over him, and. when necessary, the regular bed covering is added. In this way the clean bed i1- protected and there is no need for any extra moving of the patient if the doctor sees fit to order a bath in bed. After the bath, the rubber and blanket can be easily slipped out, and the patient rests in a \" rfectly clean bed.
Tin bath-room and clothes-room should be quite separate from the wards, but so few hospitals have this system that we shall consider in detail the other plan,
IS2
JVUKSfXG
according to which all patients arc taken directly to the wards, where the nurses, besides other necessary attentions, give them their first baths and look after their clothing and valuables. If a patient walks in. he is usually given a chair placed in the hall or room outside the ward until the doctor has given orders in regard to him. The head nurse should immediately report the admission of a patient to the ward, and
to no circumstances should she neglect to do this.
A nurse should be detailed at once to look after him, to see that his chair is comfortably placed out of the way of draughts and of passers-by. His gen- eral condition is then noted. The temperature and pulse are taken first, and if any special symptoms arc present these should be reported at the same time. The doctor will then give his orders, but if there be any (I- I iv while waiting for him, the patient must still be kept under observation and made to feel that he it receiving attention and consideration. An air of kindliness and consideration on the part of the nurse meant a great deal to a new patient. Possibly he would like a glass of water, or if he has not eaten for some time and is in need of food, he may feel too strange and frightened on his entrance to a hospi- tal to make his wants known, and the nurse should not wait to be asked, but should inquire herself. As milk is usually a safe form of diet, a glass of it may be given without hesitation. If a bath is to be given. in n woman's ward this duty devolves upon the nurse. in a male ward upon the orderly. In giving the first li.itli i. peculiarity about the patient should be noted. and the presence of swellings, lumps, scars, sores, or any kind of rash should be reported at once to the head
A NEW PATIENT
1*3
nurse, whose duty it is to inform the doctor. After the patient has been cared for, attention is next given to the clothes and valuables. The nurse in charge find* out from the patient if he has money or other valuables. She makes a list of these in a book kept for the purpose, to which she signs her name, and hands them over to the. hospital clerk, who deposits them in the safe. Absolutely no responsibility should be assumed by a nurse f<>r the valuables of any patient, and whatever is retained by him remains at his own risk. If nurses do not adhere strictly to this rule, sooner or later trouble is sure to follow. The in- spection of the clothing is a duty which usually falls to the lot of the probationer or junior nurse. She should examine each article carefully to be sure that it is quite free from parasites, and if the clothes are contaminated in this way or soiled they should be listed and sent to the disinfecting oven or to the laun- dry; in the latter event they should be marked with the patient's name and ward. If, however, they arc clean, all the smaller articles should be neatly folded together ami wrapped in I large square of coarse gingham to protect them from dust ; the dresses or nuiis should be hung up in the division of the clothes- closet assigned to them, the small articles being placed on the shelf below in a compact bundle, to which is attached a tag on which is written a complete list of the clothes, with the date and name of the patient and the signature of the nurse. (See Fig. 4).
After the patient has been put to bed and is rested and quiet — that is, in about an hour — his temperature and pulse should again be taken, as the first record may be untrustworthy if. as is likely to happen, one
|
124 NVXSiNC or both have been influenced by the excitement of coming into the hospital. A specimen of urine is now obtained (from women always by catheterization), and kept for the doctor's inspection ; at the same time one ascertains whether or not the bowels arc in a normal condition. If a new patient is very ill, if he has a chill, or if Fib. 4. |
||
|
/w.m Q \ |
||
|
N»mt of Mitt* |
||
|
ArtolM of Clothing. |
||
|
0«U. -IB© No, |
||
|
Font ro» the body or feet applied without enters the ward fort should be m; responsibility de made bed. strict thing about him |
LliTlVC TBI IVjTII! Of A are cold, hot bags o delay. From the m every possible provis ide. In this work a U volves upon the nur .•-!( •/mlincss of the pa the prevention or cs |
l'ATirMI. r cans arc to be meal a patient on for his coni- irge share "i the se. A properly tient ami even ■ ire of bed-sores, |
A HEW PATIENT
,15
suitable food attractively prepared and served, thi administration of the medicines ordered and the carry- ing out of other therapeutic measures — such as the varioiiN applications, baths, or massage, or the changing of soiled dressings in minor surgical cases — all these belong to her province, so that to a large extent the life and health of the patient are in her hands. ( )f course in the male wards an orderly is provided to perform certain duties, but the nurse is responsible for seeing that all orders for such patients arc carried out. The catheterization of male patients is usually assigned to one of the junior assistants on the medical Staff, but in the children's ward the nurse should be given an opportunity of learning the proper method of procedure in view of possible future emergencies in private duty. In hospital work under all circum- stances the modesty of all concerned should be re- garded. In a ward all kinds of work should be done behind screens, and suitable dressing gowns should always be provided for the patients to use in going to and from the bath-rooms or lavatories. The daily personal care of the poorest patient should afford opportunities for the exercise of all the refinements of nursing.
It may be impossible to give a full bed-bath at once to an invalid in a weak condition or to one to whom the bath is disagreeable, and we often have to proceed gradually. If the physician makes his rounds at a very early hour it will be impossible to complete the toilets of all the bed patients, but care should be taken to sec that their faces, mouths and teeth have been washed and that the beds are clean and in order. The finishing touches may then be left
126
tfUJfS/.VG
until the rounds are over. When there is plenty of time a full bath should be given to a bed oatient every day. and in some cases tins is absolutely necessary; but if there are many to be bathed in a limited time, each should have a daily bath at least at far as the waist, particular attention being devoted to the spaces under the arms. The surfaces between the thighs should also be cleansed daily and a full bath given twice a week. Absolute cleanliness of the body and of the bed are two most important factors in hastening convalescence. After the daily bath the finger-nails and toe-nails should be pared and cleansed. A bed patient's hair should be washed occasionally: if pre- cautions are taken, no danger of taking cold need be feared. The pillow and shoulders arc protected with a rubber sheet, the patient is moved over to the llde of the bed, and two basins are placed on the adjoining bed-table, one containing a warm solution of borax (about 2 drachms to the pint) the other warm water for rinsing. The washing can then be done quickly and easily. The hair is nibbed thoroughly and spread out on the rubber cloth until it becomes quite dry. To free hair from parasites the head is bound up for two or three days in a cloth soaked in a 1 :20 (5 per cent) solution of carbolic acid, which is kept moist all the time, the pillow of course being protected by a rub- ber slip ; or else the head is covered with a cap of oiled muslin. After the hair is dry, alcohol is rubbed in about the roots to destroy the nits, which soon after drop off. A quicker method consists in soaking the hair in pure kerosene oil for half an hour and then nibbing it well with alcohol. In a free ward it should be the nile to have every patient*! head examined
A NEW PATIBN1
127
carefully. In the case of a woman who is too weak to have all her hair attended 1" at once, a part only should be done at one time ; thus one braid might be dressed in the morning and another later. The \\ air, however, should never be allowed to go uncared for more than twenty-four hours, and if it be handled deftly, the dressing will be a pleasure to the patient instead of the ordeal it sometimes proves to be. Here, again, success comes only from much practice and per severance. Every time one has long and difficult hair to care for, one more opportunity is afforded for prac- tice, and the process should not be hurried through, but the nurse should try each time to make some improvement in her methods. The arrangement of the whole head should not be attempted at once : it is best to part the hair into two strands at the back, and then take one side, this again being sub-divided if necessary. The combing or brushing should be done gently but firmly: we should begin at the ends and work upward, the hair being always grasped with the left hand at some point between the comb and the head, so that there may be no jerking or pulling. The best way to dress the hair is in two braids, care being taken to draw each well over to the side and to braid low down just below the ear, so the patient may not have to lie on two hard lumps of hair. The first two or three turns taken should be looser than the subsequent ones.
The mouth and teeth are to be carefully looked after, and as far as possible kept clean and sweet. The condition varies much in different patients. Where the accumulation oi lordefl and mucus is rapid, and where the lips and tongue are stiff and parched, at-
118
XVKSMG
tcntinii may be needed every hour, but in ordinary ca»e» Iwicc a day or after each meal will usually suf- h ■ The mouth should be kept as moist as possible, i In imc treatment being carried out through the night »« during the day. Night nurses arc not so attentive ai they should be in this regard, and often this neglect occurs not so much from lack of time as from want r.f thought There are various mouth-washes in use. A weak solution of borax answers as well as anything. l.isterine is very cleansing and has disinfectant prop* crtics. A glass of water containing half an ounce of listerine left on the patient's stand to be used when (1 often gives great relief and comfort. A solu- tion of lemon-juice, glycerine, and distilled water is refreshing and softens the tissues ; but where fit appear they are to be treated with frequent IppliO' tions of lanolinc, vaseline or cold cream, to which may be added a few drops of the oil of peppermint or wintcrgrccn. Where the gums are soft or spongy and sore a few drops of the tincture of myrrh added to pure water may be used. The best siionges for washing out the mouth arc made of small squares of dressing gauze or old linen, since these can be burned im- mediately after being used. One of these squares ihould be wrapped about the index biger, dipped In the wash, and inserted into the mouth. Every por- tion of the cavity should be well gone over, the sponge being passed along the gums and inserted behind the wisdom teeth — a place often neglected — thence over the roof of the mouth, inside the teeth, and under the tongue. If the tongue is badly furred. It ihould be soaked and then scraped. A mod mouth-wash for
BED-SORES
\l<)
general use is: Glycerine 3j Sodium bicarbonate grs. x, Saturated solution of boric acid 5j.
A patient's linen should be changed frequently, as a clean bed and body linen go far to refresh and relieve restlessness. The nightgown and at least one pillow and sheet should be changed night and morning. It does not necessarily follow that those taken off should always be sent to the laundry; unless stained, they should be hung Up in the fresh air and sunshine for several hours, then warmed and put on again. Old, fairly plain, soft nightgowns are the best in illness, and the same holds good for the bed-linen and towels. Where there is much perspiration old soft flannel or flannelette nightgowns are preferable, and in any case a soft flannel jacket is useful for covering the shoulders and arms when the patient sits up in bed.
To guard against bed-sores is one of the first in- junctions given to a nurse who is entrusted with the care of a bed patient : the danger of such an occurrence varies with the nature of the disease and the weight of the patient. Very fat, flabby individuals and emaci- ated patients arc liable to suffer from this complica- tion. It is just here that good or bad nursing tells, and the development of a bed-sore while the patient is under a nurse's care gives ground for severe criticism. Bed-sores result from continuous pressure on a cer- tain Npot or spots, also from friction between two sur- faces, from moisture, creases in the under sheet, night- gown, or rubber, from crumbs in the bed, and from lack of proper care and cleanliness ; their formation is favored by all conditions in which the nutritive pro- cesses taking place in the body are faulty. Bed-sores
|J0
apt to coax oa the knees, or on a
bade of Be bead from fre- the bed. Those resulting from mifcsutrition of the entire system may appear at almost any place where there b the rfigt<rM preaaure. and mar thow themselves first in the form of. pustules, which are followed by a rapid breaking down of the tissues. Thia last variety is the most difficult to prevent, and 1MB with the utmost care they are sometimes unavoid- able. In patients suffering with oedema, paralysis or spinal injuries or where there is a continuous discharge from any part of the body, the utmost care on the part of the doctor and nurse will not always avail; but generally speaking, bed-sores can be avoided, and arc amenable to treatment. Preventive measures consist in absolute cleanliness and the removal of pressure, ii tlic latter, various mechanical appliances are em- I ; these will be described in the next chapter. r>«' Ixack and shoulders should be bathed with warm ■•'. it'i .mil soap night and morning, gentle massage being I to keep the *kin clean and active; they
are afterward", rubbed .vith 50 per cent, alcohol or a sOltltJoa i"ii 1 inn; of an ounce of burnt alum in a pint of brandy, Finally the parts are dusted thoroughly (since such application! h.irdcn the skin) with some kind of powder which will absorb the moisture. For this purpose the oxtdc-of-jtinc or stearatc-of-zinc pow- ' .1 n mt Ii mi - <•■ I with Itorax are of equal value. If
BBD-SOXES
«3<
there is much moisture due to perspiration or involun- tary evacuations, in addition castor oil should be well niMxd in. Tin- sheets must be kept perfectly smooth 3nd dry under the patient: sometimes even a slight wrinkle will produce redness and tenderness. As a matter of routine a bed patient's draw-sheet should be brushed off and drawn after each meal. The first indication of undue pressure is redness of the skin ; the patient may complain of a stinging sensation, but we must never depend upon him to report this, but must be on the watch all the while, so that the first sign may not escape us. Again, the redness may be followed by a dark color under the skin, and when the cuticle finally comes off the underlying tissues arc found to be broken down and sloughing. Any abra- sion of the skin should be carefully washed, and a small pad of cotton smeared with olive oil and stcaratc of zinc placed over it and kept in position with ccl- loidin. Painting the surface wilh white of egg is fairly satisfactory. Another excellent dressing is a mixture of equal parts of castor oil and bismuth. The pressure may be removed by means of rubber or cotton rings. A change of position is advisable, and where it is possible, the patient should be turned on his side, the back bcinj? supported with a pillow well tucked in. Avoid putting a patient on a blanket as the extra heat produces moisture which softens the skin and thus favors the formation of bed-sores.
If, however, in spite of our precautions, a bed-sore has formed or a patient is admitted with one, the physician is to be told at once, as he may prefer to outline the treatment himself: often, however, it is given over to the care of the w.v-< , ami then should
112
ttVRSWG
\* treated like any other wound. The part is sponged clean with soft gauze sponges, a solution of boric acid or a weak solution of carbolic acid being employed, and the cavity packed with strips of iodoform gauze or treated with iodoform or aristol ointment, over which a layer of boratcd cotton is applied. The whole is sealed with a layer of gauze dipped in cclloidin. The sore should be dressed daily. If there be a slough, hot boric dressings should be applied every four hour*, followed by an application of castor oil and balsam of Peru until granulations are established. After this for rapid recovery the treatment applicable in the case of abrasions can be used. Sloughs may also be removed by poultices, but these are seldom or never ordered now, as they often tend to weaken the sur- rounding tissues, and thus favor pus-formation. Weak granulations may sometimes require stimulation : where they arc too exuberant some caustic application may be indicated. The formula for the cclloidin solu- tion will be found elsewhere. With this preparation the use of rubber plaster to hold a dressing in posi- tion is quite unnecessary. Ordinary adhesive plaster is undesirable, not only because it is uncleanly, but on account of the irritation which it produces and the difficulty and pain experienced when it has to be re- moved.
In the first stage of convalescence from an acute disease, when the temperature has become normal or nearly so, a limited soft diet is ordered, and if the patient is allowed to sit up in bed, he is to be sup- ported by a head-rest or with pillows, In the next stage he may be allowed a little solid food and may sit up out of bed (at first only for a few minutes, the
CONl'ALESCl
»33
time being gradually prolonged each day), and from this on there will be a gradual increase in privileges until strength is restored. The second stage is more or less prolonged according to the particular case, but not until a patient is discharged do a nurse's duties cease, although their nature will be somewhat changed. With the gradual return to health the diet will need to be more varied ; each day has to be planned out so that a judicious amount of amusement, rest and variety, shall enter into it. All these arrangements fall within the nurse's province, and the shortness or tediousness of convalescence will depend largely upon the measure of success attained in her management of it. Each ;m:h nt must be treated as an individual, and the plans must be varied according to his idiosyncrasies and the nature of the trouble from which he is recovering. Especial attention is required during convalescence lest too much be attempted and bad results follow. The temperature and pulse should be taken and re- corded twice in the twenty-four hours, the amount of sleep should be noted daily, and the increase in weight determined about once a week.
When the patient sits up in bed a flannel vest should be placed under the night-gown, and the shoulders should be well protected. A loose flannel dressing- jacket is comfortable and looks well. Nightingales are very convenient to put on and off; they lit well about the shoulders, and are in every way best for hospital use. They may be made of a double thick- ness of outing flannel, arc inexpensive, and do not .shrink in washing. Unless the weather is very warm, krr.iy blankets should be wrapped about patients when out of bed or when in the wheel-ehair. White bed
«34
\URS1.\G
blankets should never be used for this purpose. If a patient can sit up in a chair to have his bed made, his feet and body arc to be well enveloped in blankets. Long loose warm dressing-gowns are the best to use in moving to and from the bed, as they are easily put on and off, thus saving the patient's strength. The temperature of the room should be slightly in- creased when the patient is out of bed.
Seeing too many friends is one of the chief evils that may befall a convalescent : friends in their joy that the danger is over do not realize that the patient'* strength has not yet returned, and should the nurse forget this fact and allow two or three persons to visit him at one time, and another set almost im- mediately after, much harm may result It is just as important during convalescence as when he is in bed that the patient should be protected from ex- citement and from any overtax of the nerves and strength ; one or two visitors singly ;it the mod -^:- sufficient for one day, and even then the time should I" limited, and no visits whatever should be allowed after 8 in the evening. A patient should have been cared for and settled for the night by 9 or 9:30 at the latest : even if he shows an inclination to talk still later, the nurse should use tact to prevent it. The I'.ni. nt should be bathed, the bed freshened, the ven- tilation regulated, the room settled and darkened, a glass of milk or some nourishment given, and finally the back gently rubbed for a few minutes, without any conversation whatever taking place.
Il is to be regretted that our large general hospitals afford sn little MOOfflfflOdltfon for patients suffering from chronic disorders ; not only for the sake of these
CHRONIC DISORDERS
'35
unfortunates themselves but for that of the nurse whose training should tit her to care properly for all sorts and conditions of patients. It would certainly be a good thing if a special course could be provided for nurses which would teach them the many ways outside of the practical nursing duties in which they could make themselves acceptable to convalescents and chronic patients.
If the condition of a patient at any time shows a marked change for the worse, the nurse should at once notify the physician, and without instructions from him she should never willingly assume the re- sponsibility of being alone with a dying patient. Some of the signs by which the approach of death may be recognized are a pinched sharp look in the face, cold- ness of the extremities, a dark-bluish color of the finger-nails, and a dusky pallor of the face. Death actually occurs through the stoppage of the heart or syncope due to failure of the circulation, or by the failure of the respiration or asphyxia. The exact time of death should always be noted.
Everything should be done for the peace and com- fort of the dying patient, but judgment must be exercised inasmuch as meddlesome attentions may sometimes c.ium- positive distress. Thus to give stimu- lants frequently after the act of swallowing has be- come a gieat effort is not advisable. The duty of informing the friends as to the patient's condition rests with the physician, but in his absence this sometimes devolves upon the nurse. It will lessen the mental strain to remember that the actual suffering felt by the dying is practically nil. as towards the end the process becomes purely mechanical.
i36
S'U*SfNG
Whether she is in a hospital or on private duty, a nurse should always see that the propcT arrange- ments are made after death. Her duties to her patient <b not cease until the body has been decently cared for and the bed and room have been left in perfect order. In a hospital it is desirable to remove all traces of death as soon as possible, on account of the other patients. The limbs should be straightened before rigor mortis or stiffening of the muscles begins, the eyes should be closed, and the jaws held in position by means of a support placed firmly under the chin ; for this a roller bandage or a small piece of wood which has been covered with some soft material is generally employed. The nostrils, mouth, rectum, and vagina should be packed with common or absorbent cotton in order to prevent the escape of the post- mortem discharges. After this has been done the body- should be bathed with a 2 per cent aqueous solution of carbolic acid ; if there arc any wounds, they should be covered with fresh cotton and then neatly bandaged ; if it be necessary the hips may be enclosed in a large triangular binder: the knees are to be held together by a broad bandage; the hair should be bnuhod smoothly; and finally stockings and a simple night- gown should be put on. If the case be one of in- fectious disease, the body should be wrapped in a sheet which has been wrung out of a 5 per cent, aqueous solution of carbolic acid, and which should Ik- kept damp. In a hospital, as soon as these prepara- tions have been completed, a card should be made out with the name of the patient and of the ward, her 1. 'ill il" hour at which death has occurred; in. I this should I* Mill with thf body, which is to be
CARE OF THE DEAD
»37
at once removed from the ward. A nurse should never mention or discuss a death with any of the patients. When on private duty, as a rule, the nurse has little further to do; but if it should be necessary, she should be ready to offer suggestions, so that the arrangements may be made with as little trouble to the family as possible. She should not leave the room until all is in order and all traces of her work have been removed. Where there is no one else to look after the proper disinfection of the room, the duty of seeing that this is properly done will devolve upon her.
CHAPTER VII.
Baths. — Classification. — Temperature. — Baths ro« Clean- liness.— Tub-baths.— Foot-baths. — Baths as Thera- peutic Agents.— Ifuanun Baths. — Simple Hot Baths. — Hot-air, Steam, or Vapor Baths. — Salt-water Baths. — Bhajc and Stajoch Baths. — Sponge-baths and Tu»- baths in Typhoid Fever, — The Cold Pack.— The Con- tinuous Bath.
Baths may l>c classified according to the temperature at which they are employed, the special purpose for which they arc used, or the method of their prepar- ation. Simple baths arc usually spoken of as hot, warm, tepid, or cold. Thus, broadly speaking,
A hot ti»lh mar v»f y in temperature from IOC* lo 11!' F. or higher. A warm " 90* to 100* F.
A tepid " " TO* to 90* F.
Auol " 68* to *0*F.
A cold " " " *J*to 45* F.
The temperature of baths (or health? Inland and young children mai v»r » Irom 85* to 80° F.
The baths that come within the province of a nurse's work arc given for cleanliness, to reduce fever or inflammation, to induce perspiration, to produce gen- eral relaxation, or to modify the circulation of the blood. The temperature and duration of a bath for any given patient are determined by the physician.
Baths for cleanliness may be given cither by spong- ing the patient while in bed or by immersing him in a bath-tub. To give a bed-bath a nurse must first have on the spot all the things which she will require. It
134
BATHS FOK CLEANLINESS
*39
is exceedingly bad management, and not a little trying to the patient, if, when ond »h« hu begun her work, the nurse is obliged to stop at intervals to fetch sonic- thing not at hand. The old proverb, "The head should save the heels," applies no less here than elsewhere in a nurse's work. As the time for the morning bath is also that for changing the bed-linen, the fresh sheets, pillow cases and night-gown should all be warmed and ready to put on ; the face and Turkish towels, brought at the same time, should be warmed by hanging tin m before the fire or by wrapping them around a hot- water tin. The nurse should have beside her a good- sized pitcher of hot water and another of cold water, a slop-jar for changing the water, a bath basin, and two single bath blankets. The other necessary articles will be found in the nurse's toilet-basket The night clothes arc taken off the patient, and she is al- lowed to lie between the two blankets. The body is to be bathed in separate sections, each being thorough- ly dried at once, the face, neck, and arms being first taken, then the chest and abdomen, next the feet and legs, and finally the back and surfaces between the thighs. Tlie entire bath can be given under cover, or at any rate no more than one part need be exposed at one time, and the whole procedure should not last longer than fifteen or. at the most, twenty minutes. The first bath, however, may of necessity take longer than this, and if a patient is very dirty a few drops of aqua ammonia or a little borax powder added to the water will be found useful. Either of these will be of advantage if the odor of perspiration is un- pleasantly strong; in any case, a little alcohol or can de Cologne will l>e found refreshing, though to some
K/tatsmG
■ veil this may not be agreeable. Towels
ihouM be ttw •||'. damp ones tbould
■ u\,\ \: ,|. ''..'. In, w.iur should be kept pleas-
.uiily warm by being changed twice or three times
MUM of the bath. If the patient seem
, \h ml. I ut.i it. a glass of hot milk or some form
of li|;ht food may be given, and if the feet are at all
be applied.
, inn ! s .iiv extremely untidy about giving a
ith, On entering a ward one is sometimes con-
,1 with • screen about a bed. from underneath
,, In. h in .mi all around on the floor, can be seen, per-
luipn. a hot-water can no longer needed, the nurse's
buket, I towel or two, or the soiled linen just
ii moved from the bed. Such a scene speaks, louder
i i word* for careless work on the part of the nurse
in charge.
Patients, if wheeled into the bathroom.can frequently
take their bath in the ordinary tub, or at the
hctUidc if I portabfo tub be procurable. If able to
themselves the bath, the nurse must remain
near at ban. I, lest they should become faint or need
..in assistance. In giving a patient a bath, a sheet is
|i. id over her and she is lifted in, the sheet being
left to cover over the top of the tub, since it would
,.i«.e interfere with sponging. The method of
giving ili. mb-bath in the case of typhoid-fever
!•>' i. hi. i iscwlicrc. When ready for bed
the patient may Ik- lifted out again under cover of
the name sheet, and plaeed on a second, well-warmed,
I . ■ • r . in wlnoli she || Wrapped \ Uankct is then
ii over her, and she is left f< >r a fe% moment!
until all moisture is absorbed and she is rested.
_
FOOT-BATHS
l4l
Foot-baths may 1* given in bed. but a rubber sheet must be spread across the lower part of it in order to protect the mattress. The patient lies on her back, bends the knees, and places her feet in the tub, which is arranged lengthwise in the bed. The same method is followed in giving a mustard foot-bath, except that the knees and foot-tub are enclosed in a blanket. Mus- tard foot-baths are often prescribed for severe COWa where the symptoms are mainly confined to the head. and for headaches where there may be too much blood going to the head, the object of the bath being to dilate the blood-vessels of the extremities, thus bringing more blood to these parts, and In this way equalizing the cir- culation. Hot water alone will do this, but the addi- tion of mustard hastens and increases the effect. The amount of mustard to be used varies according to the strength of the mustard and the sensitiveness of the skin ; it should be mixed with a small amount of water and made into a paste before being added to the bath. The feet are allowed to remain in for from fifteen to twenty minutes, the water being kept at the same tem- perature or made warmer by adding more hot water from tinif to time; they are then taken out. wiped gently, and tucked in snugly with blankets. What it is necessary for any reason to increase the circulation in the lower extremities, this is usually the method em- ployed— a procedure often advantageously combined with friction and the application of hot- water bags or cans.
The physiological action of the different form* of the hot bath (hot-air, vapor, and steam bath) is very much the same. When given to induce perspiration (diaphoresis), the utmost care should be taken to sec
,\'VkStMG
ttti, ,. us are thoroughly made and that
fully carried out, for without such ^ tin labor will be in vain; and it is folly
bul n partial result where only a copious m n be of any avail. To give a hot tub- in purpose, the tub i.s half filled with water at
I drawn to the bedside; the patient is lifted
ili.' temperature of the water gradually in-
I the thermometer registers about no'-
I This temperature is maintained for from i ii Hi-en minutes, after which the patient is lift-
i i prepared bed, on which a long rubber is
I with three or four hot blankets over it ; these
i In wrapped all around her, tucked in closely
I I he neck, and watched continually so that no air
Plenty of wati r is given to drink, as the more
m ii in the body the more profuse the per-
will be and the greater the amount of the im-
iilirlti' removed. After the sweating process has • i up for about an hour, the patient i> gradual- red, sponged under a blanket with alcohol mid water, and the wet blankets are removed. Dur- ing Well baths cloths wrung out of cold water are ap- i ||m| to the head. It is well to keep the fingers on lllft when the patient is in the bath, and on the ndication of faintness to remove her to bed im- nic.liately.
I 1 1' hot water dilates the superficial blood-vessels,
tin pores of the skin OC sweat glands have their activ-
I mMd| their orifices arc freed from any accumu-
and urea and other waste matters in the blood,
i normally should have been given off by the skin,
or which have been retained in the system owing to an
WARM BATHS
'43
inadequate excreting power of the kidneys, arc carried off with the perspiration. This effect continues only as long as the vessels are well dilated and the skin- gtands active, and, as we have said, is much assisted by copious draughts of water. As regards the time during which the bath should be continued no hard and fast rule can be given, one patient obtaining the whole benefit of the treatment in half the time that would be necessary in the case of another.
Hot baths should not be given during the menstrual period or in the last stages of pregnancy.
Warm baths are frequently prescribed for convul- sions in children, as the heat relieves the muscular tension and pain, equalizes the circulation and pro- duces sleep. When given for influenza they are often ordered hot at first, the temperature of the water being afterwards reduced by the addition of cold water in order to produce a better reaction.
When pilocarpine or some similar drug is ordered, its diaphoretic action should be assisted by wrapping the patient in two or three dry blankets, placing plenty of hot cans at the sides between the blankets, and over all spreading a large rubber sheet to condense the heat and exclude the air.
I Uless special appliances arc available for giving the hot-air. vapor, or steam baths, it is difficult to make them thoroughly successful with only an average nurse, and it is better to rely upon the hot-water bath. The wpor both presents the least difficulty. The patient is placed on a long rubber sheet and blanket and covered with another blanket, tucked in snugly .ilxiut the neck. < '. > her are put two small bcd-eradlcs, high enough i -import the weight
AOA'S/A'G
<A tttt centring ; the cradles arc covered with
i all comes a long rubber sheet.
. .. with large safety pins at short dis-
- *V1*^ the siiles of the mattress, rendering the
«<*cv a* ;•'■ BS possible. A small opening is
l*A *V the cud of the bed for the introduction <>f a
• . oi rubber tube attached to a kettle of
should lie kept boiling by means of a
.'.-.»' ^ t. .tow or alcohol lamp. A patient CM be left
half an hour to an hour, and is then
^<OM4;cl «\ j Iter the hot bath. This is the most simple
itejun apparatus and can be readily impro-
in private practice. A small Arnold steam
can he converted into an excellent steam
b) making a small hole in the top into which a
.11. .1 More elaborate forms of appar-
iionlv found in hospitals. An alcohol
kettle i nd tube can be used for moistening the air
of croup or other laryngeal diseases.
i ktti air bath air may be heated by means of an
up and introduced under the canopy. The
Mturc of the air for a hot air bath at first should
ntngV hom i»* to 1300 F. When the latter tempera-
I .1 small opining should be made at the
1 1,, tent which should be utilized periodically in
ID of the escape of the moisture. When
pbtN within the tent is dry the heat may
yi.imiallv In- increased until it reaches 200* F.
If llie (valient is able to sit up he may be put on a
chair with his feet in a foot-bath of hot water; the
ftlolhinfl bfting removed, he is then covered in closely
»iih blanket! faateoed like 1 tent from his neck down
l the chair and reaching to the floor. An alcohol
BATHS AND PACKS
'45
lamp in a large tin basin underneath the chair is then lighted, and if the patient ll kept well wrapped up lie will soon perspire freely. After he returns to bed. he is sponged as after other baths. For the "baking pro- cess," i.e., the treatment with dry superheated air now so commonly employed in various diseases, especially in certain cases of rheumatism and arthritis deformans, copper cylinders lined with asbestos are commonly em- ployed. These arc of various shapes and sizes, being large enough to admit the- whole body or a part, such as an arm or a leg.
Local baths and packs are used chiefly to relieve in- flammation. Thus for sprains a foot-bath, in pelvic inflammations — for pain, or to induce menstrual dis- charge^— a sitz-bath is frequently ordered. In the lat- ter the patient occupies the sitting position and only the thighs and part of the trunk are immersed, while the upper part of the body and the feet are protected with blankets. These baths are given in tubs specially shaped for the purpose.
A salt-water bath is ordered for its tonic effects. It can scarcely take the place of sea-bathing, but where this is not obtainable or where for some reason or other it is contraindicated. the following will be found a good substitute: Sail may be mixed with the ordinary bath-water in the proportion of from 9 to 14 pounds of sea salt to 50 gallons of water ; such a bath will be strong enough to redden the skin and will generally have an exhilarating effect.
For certain forms of skin disease, starch, bran, or al- kaline baths may be ordered to allay irritation. The starch bath is made l> adding eight ounces of laundry starch to each gallon of water. For the bran bath the 10
146
AL'USItfti
bran is put in a bag which is allowed to soak in warm urates for an houi inhuc being used, or it may be boiled for a quarter of an hour and then the fluid drained ofl" and added t" the bath water. Medicated baths other than these — with the possible exception of the so-called Schott baths — rarely come within the province of a nurse in private practice, as anything like satisfactory results from them can l>e obtained only in sanitaria or hydrotherapeutic institutions fitted up With all the proper appliances, where the whole course of treatment is systematically taught and carefully supervised.
For the local chest-pack used in pleuritic and other conditions, a piece of llannel two yards long and three- quarters of a yard wide is folded lengthwise and rolled, dipped in either hot or cold water, wrung out as dry as possible and applied to the chest in the form of a figure-of-eight bandage, being passed across the chest from the left armpit over the opposite shoulder, across the back under the left arm, across the chest under the right arm, round the back and over the left shoulder, and fastened with a safety pin. Over this is put on a double pneumonia jacket covered with oiled silk. Af- ter the removal of the pack the skin is nibbed with 50 per cent alcohol.
Haths and packs arc also employed in functional nervous disorders for their tonic or sedative effects. For the latter warmth is used, as it relaxes the nervous tension and promotes quiet and sleep, whereas cold tends to increase the circulation, stimulate nervous action and give tone to the muscles. When • sol.itive effect is desired quiet i stimulation is
BATHS ASD PACKS
'47
indicated. Cold baths or packs may advantageously
be followed by massage or oilier exerci
The warm pack is sometimes ordered for nervous- ness or sleeplessness and is often useful in chorea. A single blanket is put to soak in hot water. The bed is then prepared with a long rubber sheet covered by a single dry blanket upon which tin patii Dl is laid. The blanket is then wrung as dry as possible out of the hot water and wrapped about the patient up to the neck. In the case of children the arms should be folded across the chest and enclosed in the blanket. Over all comes a dry blanket. Care must be taken that the blanket is not hot enough to burn the patient ; but at the same time it must not be too cool. After run my minutes the patient is taken out. rubbed dry gently, given a drink of water and left to rest.
The same result is sometimes obtained by means of the spinal hoi sponge bath. The patient having been made comfortable, a »i>onge wrung out of hot water is applied with long even strokes along tl»c spine which has been left bare. The procedure lasts for fifteen to twenty minutes after which the patient usually drops off to sleep.
The cold pack is also sometimes ordered in condi- tions of delirium, of extreme nervousness, and to in- duce sleep. In such cases one sheet only is required This is wrung out of cold water, and the patient wrapped in it, the feet being left free. She is then en- veloped loosely in blankets, and allowed to remain for from twenty minutes to an hour. If the feet are cold a hot can may be put to them. Where symptoms of delirium arc present an ice-cap or wet compresses made
i48
AY/A'5/.VY7
of gauze must be kept constantly applied to the head; in many other cases they are a source of comfort.
The drip-sheet bath is used largely in the rest- cure treatment. In a properly warmed room the pa- tient stands in a tub containing tepid water a few inches deep; a sheet is dipped in this water and while dripping is wrapped quickly about the patient from behind, each limb being encased in it. Rapid friction is then made by the nurse who stands at one side of the patient, and rubs briskly the back and front at the same time, and afterwards the sides and extremities. If the patient reacts quickly cold water may be thrown over the body and the rubbing repeated. The sheet is then taken off. and the patient after being nibbed down with warm towels, is put to bed. The feet are massaged and if neeevs,u\ a hot-water bag is applied. If the patient is up and about she may be warmly dressed and sent out for further exercise. The whole bath should be over in from three to five minutes.
A favorite method of applying shock to the nerv- ous system is by the cold douche, either local or gen- eral. It should be given with considerable force, very quickly, the sensitive part being treated last.
The cold sponge bath, the cold park, and the cold water tub-bath are employed chiefly for the reduction of temperature in typhoid fever, and occasionally in pneumonia or other acute infectious diseases.
In giving a sponge-bath to reduce temperature the nurse should disturb the patient as little as possible; if the bathing has to be repeated often, the continual moving irritates a typhoid patient and may aggravate the nervous symptoms. It is not absolutely necessary to turn him over and spread a long rubber sheet mi
A SPOAfGA BATH
149
der him, the only object being to protect the bed from any moisture, and this can be done by means of two large bath towels or a small draw-sheet. In preparing to give a sponge bath there should be ready (1) a rubber sheet or two large towels to protect the bed ; (2) a towel of medium size for spreading over the abdomen; (3) two small ones as compresses for the head (or an ice-cap) ; (4) two medium-sized sea- sponges; (5) two basins, one for the towels and com- presses, the other for ice-water; (6) a rubber to pro- tect the pillow. A wet compress is kept on the head all die time. Whenever the compress becomes at all warm, it should at once be changed for a second, which has been put on ice ready for the purpose. As a role the temperature of the water is regulated by the amount of fever present. The higher the fever, the cooler should be the water. A steady temperature of about 650 F. can be maintained by using lumps of ice. A foot-bath tub is the best kind of basin. M its use obviates the necessity of changing the water. The patient is covered with a sheet, and the body is gone over in sections just as in the bath for cleanli- ness: the sponging, beginning with the face and neck, proceeds to the arms ; it should be done with long light downward strokes, as the object is to bring the water in contact with the body without producing friction. The sponge is changed after every third or fourth stroke. After the arms, the chest and abdomen, and die legs and feet, arc taken, but before going on to these a wet towel is wrung out and spread over the chest and abdomen. This should be changed frequently. Finally, the patient is turned over on one side with the towels tucked in, so that the back
i5o
NUKSIiS'G
may be sponged; if very weak she can be supported with one hand while tin- oilier is used for bathing. The exposure of the parts being bathed to the air assists evaporation, and hence materially aids in the lowering of the temperature, and it is also better not to rub the patient dry. Five minutes' time is given to each section, the parts where large blood-vessels arc near the surface being sponged longest. Pieces of ice wrapped in a cloth and laid in the axillary spaces and along the carotid arteries are often useful. The legs the knees down require less sponging since they usually cool quickly. The whole bath occupies about twenty minutes. The patient is now turned on her back, a gown open all the way down behind, but closed in front, is slipped on, and the temperature taken. The patient should be encouraged to drink plenty of cold water during the bath.
Fever can also be reduced by means of evaporation alone. For this purpose towels or gauze wrung out of tepid water are spread over the patient's body and she is then exposed to the air, and fanned, the towels being changed once or twice during the treatment, which should last about 20 minutes.
The simplest way to apply the cold pack to reduce temperature is as follows: A long rubber sheet having been put on the bed and covered with a blanket, two sheets are taken, and folded separately lengthwise into four thicknesses. They are then wrung out of COM water at 6b° F. or 65* F., and placed one under the other over the patient, being tucked snugly in about the neck, under the arms and sides, and carried down to the ankles. The sheets are removed at the end of fifteen minutes and the procedure is repeated.
A 1VH- BATH
It requires four such packs of fifteen minutes each to equal one bath of ten minutes, but in spite of this the pack is sometimes preferable, and is more par- ticularly suitable for children.
An affusion to reduce temperature may be given wrapping the patient in a sheet and placing him a canvas cot, and then sprinkling him with water from an ordinary watering-pot. The procedure may also be carried out with the patient in bed by elevat- ing the head of the bed, protecting the mattress with two long rubber blankets, the second being allowed to hang over the foot of the bed so that the water drains into a pan. At first the sprinkling is done with tepid water, but by degrees cold water is substituted. A towel should be sprc; or the chest and
loins. A collapsible rubber bath-tub is now obtainable which takes the place of the above contrivances; its use affords a great saving of strength to both patient and nurse.
Tubbing the patient is an excellent way to reduce temperature. This method, introduced by Brand, Whose name it bears, was used by him with extraordi- nary results, which have been confirmed by the ex- perience in our best American hospitals. Where it is used, a temperature of 102.5" F. is generally an Indication for the bath. A portable tub is necessary. This is filled two thirds full of water at a tem- perature of 850 F. and rolled to the bedside. The nightgown having been removed, the patient is wrapped in a sheet and lifted in. the feet being im- mersed first, and the body gradually lowered until it is completely covered. The hands remain free, as the pulse must be watched. A> ledge at the head of
1 5i
JVU&S/.VG
the bath lias a rubber pillow or ring on it, upon which the head, covered with a cold wet compress (towel or sponge) . rests. The temp< rature of the water is gradually reduced until it reaches 75* or 70° F.. the desired point being maintained by adding ice from time to time. After the bath is finished a dry sheet is spread over the tub, in which the patient, freed from the wet one, is wrapped as she is lifted out She is then placed on a long rubber sheet on the bed and covered with a single blanket. In about ten minutes the wet clothing is removed and she is wiped dry. The rectal temperature is to be taken at once, and again three-quarters of an hour later. For the nervous tremor or bluencss (the latter especially being not infrequent) during the hath continuous friction should be applied to all parts of the body except the abdomen. Either the hand or a long-handled flesh- brush covered with flannel may be used for this pur- ' pose. When in bed, if the shivering should continue, the patient should not be covered with a number of blankets, but a hot can should be placed at the feet and the friction continued, the rubbing being always towards the heart, and any stimulants or nourishment that may have been ordered should be given. Some patients find a temperature of 85* F. too cold and the shock too great, in which case one may start with water about 95° F. and then gradually reduce il»e temperature to 75* or 70* F. by adding ice. The aver- age duration of such a bath is also from fifteen to twenty minutes: the first one should last only about ten minutes, so that the patient may become accustom- ed to the treatment. The nurse who has never seen such a bath given before may be alarmed by the con-
A TUB BATH
'53
dition of the pulsi-, which becomes hard and small, but this is due to the contraction of the superficial blood-veMetoi with consequent increase in the arterial tension, and is not serious. A soft intermittent pulse is a different matter, and is a danger signal; the patient should be removed at once to the bed, hot water bottles should be placed around her, stimulants should be given and friction employed. Old people and children usually need baths at the higher tempera- tures as they do not stand intense cold well.
The advantages of a cold bath are: (i) its anti- pyretic effect; (2) its quieting effect on the nerve- centers, whereby delirious symptoms are frequently checked and sleep is induced; (3) the modification of the circulation, shown by the slower and stronger pulse: (4) the increased excretion from the body of poisonous products. Statistics show that this treat- ment has greatly reduced the mortality in typhoid fever, and the same is probably true for other febrile disorders. The increased frequency of breathing which ensues when the patient is first immersed gives more oxygen to the lungs and aids in the propulsion of blood through them. Haemorrhage from the bowels, peritonitis and cardiac failure arc regarded by many physicians as contraindications to its use.
In afebrile cases the cold bath is sometimes ordered to stimulate the circulation or for its effect on the nervous system ; it should then be given in the morn- ing and ihould not last over five minutes. The patient is to be vigorously rubbed immediately after it. and if reaction does not set in warm drinks should be given, external heat applied, and the friction continued.
As accuracy is an important feature, there should
, i NUKStNG
v,tt> [W\ i to teal the temperature of the
nut trust implicitly to the subjective
mt surgical bath is used in certain cases |.ni.itmn wounds, in extensive skin lesions. Until after operations upon the bladder Upri pubic drainage is employed, and in id cases. The patient's whole body is im- 'ler, kept clean and at a uniform body I nil can be best arranged where a per- il •. through the tub can be obtained; where impiis-ihle. warm water must be added at fte- 11 i .ils, the bath thermometer being carefully ,: >iilitil. The dressings are removed, and a short I having been put on, the patient is sus- i hammock on strips of canvas fastened leg of the tub; the head and back arc sup- i by rubber water pillows. In order to keep mp rtture more uniform and to restrict evapora- !;. lull is covered with a rubber blanket (with
(l I'Ur downward) supported on a framework of
tints. If any dressing or irrigation of the bladder
lii I. the hammock is slightly raised until the
Itry portions of the body are exposed and the
I nl.itions can then be carried on without taking
i li> patient from the tub. If carefully looked tu. the i in. iii finds such a bath very comfortable and sleeps ..ml cits as usual. Every morning and evening he is lni< d OUl and dried; before he is returned to the tub given the usual daily bath and the parts to be immersed are anointed with lanolin. Every precaution must be taken to protect the patient from udden chilling. If necessary the bowels may
THE CONTINUOUS BATH
HS
be opened at this time by means of an enema. Before the patient is returned to it the bath-tub is thoroughly cleaned.
The continuous bath is also applicable to a single limb or part of a limb. For this purpose a foot-tub or a bowl (filled with water or with various solutions) of suitable size may be employed.
In hospitals for the insane maniacal patients are often kept for hours or days in a warm bath. This procedure often exerts a remarkable sedative influence and in appropriate cases is much better than the em- ployment of drugs.
CHAPTER VIII.
Enkmata— Kinds— Mi Tiirnr- of Preparation.— Frequency
AM) MiHiKX 1)1 AliMINISTHMION.— CaKK OK Al'I'I.I ANCES.—
Douches. — Catheterization.— I.avace of the Bladder.
There are various methods employed for injecting fluids into the body. When they arc introduced into the intestines through the rectum, we speak of giving ou-mala (singular enema, with the accent on the first syllabic). Since the purpose for which they arc used are manifold, there are many different kinds of enemata.
A convenient classification is as follows:
1. Simple, laxative, and purgative enemata.
2. Nutritive enemata for the introduction of nour- ishment.
3. Sedative enemata for local or systemic effects.
4. Astringent enemata which check hemorrhages and diarrhoeas; e.g. hot water or ice water, solutions of alum or of nitrate of silver.
5. Emollient enemata for soothing irritated and painful mucous membranes: starch and certain drugs are used for this purpose.
6. Antispasmodic enemata to relieve flatulence — e. g. the turpentine enema.
7. Anthelmintic enemata for destroying worms: salt, turpentine, and quassia arc used in this way.
8. Antiseptic or germicidal enemata, used in the various forms of dysentery.
is6
LAXATIVE F.N EM AT A
'57
9. Stimulating cncmata — e. g. hot water, hot coffee, hot whiskey Ud water, salt and water.
10. To relieve thirst — water, Oj, or normal salt solution. Riven high.
General Directions for Giving an ENEMA.
The patient is placed on her left side with the knees flexed, since the sigmoid flexure of the colon lies in the left iliac fossa, and the fluid will thus be more retained; the bed is to be protected with ■ rubber sheet and a towel. The bed-pan should be ready and under these and all other circumstances should always be given to the patient comfortably warm. In very obstinate cases of constipation the knci chest position is ordcredj bul this 1- rarely neces- sary. The basin of water is placed on the rubber sheet and the enema administered under cover.
For a simple enema the amount for an adult varies from one to four pints, for a child from a half to one pint, and for an infant about two ounces are sufficient. The best time to administer a simple enema is iii the morning just liefore beginning the toilet.
To give a simple enema ordinary suds are made with
rastilc or good brown -nap .-m<l water, the temperature
of which should be about 95* F. when ready for use.
A bulb syringe is used, care being taken to fill it to
the nozzle before introducing the latter into the rectum,
iir air left in tin- syringe will pass into the intes-
snd may cause pain. The bulb syringe is better
than any other form, is a certain amount of intermittent
pressure, which is necessary, can best be oh-
' in this way. The nozzle is always oiled or
ned before introduction, as the soapy water will
58
MJftS/XG
not lubricate it sufficiently. Forcible insertion of the nozzle is to be avoided, and one must be careful to pass it in, following the natural curve of the rectum, for a distance of two or three inches. If the point of the nozzle should meet with any obstruction, no attempt should be made to force it in, as the impedi- ment is cither the wall of the rectum or an accumula- tion of faecal matter, which will have to be removed before proceeding further. The water is to be intro- duced slowly in a gentle and steady stream. The main object is to distend the rectum by means of the water sufficiently to produce reflex stimulation, thus in- creasing the peristaltic action and as a result bringing about a complete evacuation of the contents of the lower bowel. If rapidly and spasmodically injected, there will probably be pain and an intense desire for immediate rejection. After the full quantity has been given, the patient should try to retain it for ten or fifteen minutes in order to obtain satisfactory results. A folded towel placed against the anus will assist the patient in resisting the desire to expel the intestinal contents.
If one simple enema is not effectual, the procedure should be repeated in half an hour, a larger amount being given. Sometimes, after operations or where the action of the bowels has been sluggish, a laxative injection instead of a simple enema is given ; or the lax- ative enema is followed by a simple enema in the course of half an hour. The laxatives ordinarily used are warm olive oil or glycerine, the former softening the faeces, the latter increasing the peristaltic action. If olive oil is ordered, the average amount is six ounces in a hard-rubber syringe ; a simple oil enema is seldom
LAXATIVE EXE M ATA
'59
successful unless followed by the soapsuds, which should be given half an hour or an hour later. To give a glycerine enema, half an ounce of glycerine is mixed with the same amount of water at a temperature of 950 F. and given with a hard-rubber syringe. It is rarely necessary to inject warm water afterwards, since the glycerine and water usually prove effectual. Sometimes, however, it becomes necessary to rejient the injection in an hour. In mild cases from half a drachm to one drachm of glycerine is enough, and for children Ifld infants the contents of a straight medicine-dropper will prove effectual. Glycerine is irritating to the skin and mucous membranes of some people, producing a sharp, burning sensation. These unpleasant effects can be modified by adding equal parts of olive oil. When laxatives per rectum fail, pttrgativ« encmata are resorted to. These arc made by adding drugs, such as turpentine with Epsom or Rochellc salts, or castor oil. in certain proportions to the simple enema. In giving castor oil and water it is inn ssary first to make an emulsion by mixing the oil with the yolk of an egg and shaking well ; the warm soapsuds arc then added.
Formula l. Castor oil. Jij; Turpentine. Jjs.
Mix. and introduce with a hard-rubber syringe, fol- lowing, in half an hour, with a quart of soapsuds.
Formula i. Turpentine. )*•; Roclicllr or F.psoin salt*, Jj; Mix Willi warm soapsuds. Of.
i6o
NUtiSf.XG
I l: Rochelle salt* arc the better, as they dissolve quickly. Sometimes it is necessary to introduce the oil or glycerine high up. To do this a rectal tube or a rubber male catheter 11 attached to the end of the syringe, ami passed up the rectum for six or eight inches.
Of the various cnemata above described, undoubted- ly ihrit with the half ounce of glycerine gives the best results in ordinary cases, but for very obstinate consti- pation or after an operation, where it is imperative that tlif lxmels shall not be obstructed, the turpentine and Rochelle salts arc the best. After turpentine has I" i i! used the buttocks and anus must always be wash- ed off with warm water.
\ utritive numata, as the name implies, are in- tended to nourish the body, and are given when food cannot be retained by the stomach, when it is neces- sary to allow that organ to rest, or where the system requires more nourishment than can be given by the mouth. They should not be given oftcner than once in four hours or six times in the twenty-four hours, and the quantity administered at any one time should not exceed four ounces; the frequency and amount are, however, generally regulated by the physician according to the nature of the case.
A nutritive injection should never be given just with- in the rectum, as may be done with an ordinary enema. Absorption by the mucous membrane of the large Intestine goes on Slowly, much more so than in the small intestine, where this process normally takes place. Moreover, the absorptive power of the rectum is less than that of any other portion of the large intestine. Thus we shall not uncommonly find that
NUTRITIVE ENEMATA
161
a part at least of a nutritive enema may lie unabsorbed. and as it decomposes cause irritation of the muco'is membrane, until a second one is given, when a portion of both will probably be rejected. Tliis kind of enema, therefore, should always be introduced as high up as possible, about ten inches, and for this reason should be given through a rectal tube made of heavy rub- ber about a quarter of an inch in diameter, of which at least eight inches should be inserted into the bowel. This thickness will be sufficient to prevent the tube from coiling up on the inside, as very often happens where one of soft rubber is used. The tube, however, must not be so stiff as to endanger the integrity of the walls of the intestine when moderate force is used in introducing it. After being well oiled the tube is gently inserted in a backward ami upward direc- tion, and to the outer end a small glass funnel is attached. The enema, having been previously mixed in a small pitcher, is poured very gently and very slowly into the funnel, which is then elevated, so that the contents will trickle through the tube. In this way no air is introduced. A folded towel should be slipped under the patient to catch any drops and to receive the tube when withdrawn. After each time the tube is to be washed out thoroughly by allow- ing warm water to run through it, and should then be kept in a solution of boric acid. To prevent irrita- tion of the mucous membrane where the enemata arc to be given for any length of time, it is well to irrigate on each occasion with simple warm water, or a weak solution of boric acid, using the tube in the same way as for an enema, and then lowering it so as to allow the water to run out. This precaution
1 62
NURS/.WC
will enable lis also to make sure that the bowel is empty before giving a nutritive enema. Food given in this way should be very nourishing, and concen- trated substances, such as extracts of beef, beef-juice, eggs, anil milk, arc generally used, stimulants of some kind being often added. Two excellent formula: arc
I. One whole* egg; Table salt. grs. xv; Peptonized milk, $iij;
Brandy, Jst,
-
Or 3. The white* of two eggs; Peptonized milk. Jij.
Thc whole amount should never exceed four ounces. The addition of the salt aids in the absorption of the cpg.
Brandy and whiskey are very irritating and should be given only every other time, unless especially ordered ; if omitted, the quantity may be made up by adding another ounce of milk. For stimulating encmata the brandy or whiskey is best given in strained barley water. The milk should always be peptonized, and can be rendered so by adding twenty grains of Fairchild's prepared pepsin to one pint of milk. The vessel containing this is allowed to stand Cor fifteen minutes in water at a temperature of 1000 !■".. and afterwards placed immediately on ice.
The pure beef juice is given in quantities of from an ounce to an ounce and a half twice in twenty-four hours; four junccs of bccf-esscncc may be given and repeated once. After a nutritive enema the patient should be kept quiet on her back for twenty or thirty minutes.
RECTAL MEDICATION
Rectal Medication. Sedative medicines arc some- times piven by the rectum. Among these the bromides and chloral arc administered for their systemic effects, ;mil opium in some form more especially where there is localized pain. These drugs should always be given with the tube inserted at least six inches.
In shock or collapse four ounces of strong coffee or brandy and a liter of hot water or normal salt solution to which have been added thirty grains of ammonium carbonate, are often given high up. A small pillow placed beneath the hips will help the flow upward.
Rectal injections of normal salt solution have come to be an accepted form of treatment in many diseases. After major operations a liter of warm normal salt solution is usually given before the patient is taken off the table. They are often employed in sunstroke ;.ml shock, as a stimulant and for blood depletion after hemorrhages. In acute nephritis they may be given slowly drop by drop, the tube of the syringe being clamped not too tightly. These injections act as a stimulant to the kidneys and counteract the effect of uremic poisons. For flushing the colon with normal salt solution, from two to four liters at a temperature of 110° F. are given with a fountain syringe, the whole amount of fluid being introduced and then siphoned off. In rectal irrigations a double rectal tube should be used to permit the entrance and outflow of
water.
In hemorrhage from the bowels hot-water or ice- v. iii r injections maj be ordered. These are best given with a fountain syringe the tubing of which is at- tached to the rectal tube by means of a glass pipette.
NUKSfXG
The bag can In Imng up, lint not high enough to pro- duce any great force, the flow of water being bted by the pressure of the fingers on the tube. If necessary the bag may be refilled as soon as it is empty. For a patient suffering from peritonitis the injections arc given in the same way. plain water being used with absolutely no force. This is the most con- venient method also where astringents, such as nitrate of silver and alum, are dissolved in large quantities of water for irrigation of the intestines in dysentery.
For ether patients the enema should be given never less than two hours, usually three, before the operation, particularly in operations for haemorrhoids and in gynaecological work.
A rash not unlike that of scarlet fever and as- sociated with some degree of irritation may follow the frequent giving of enemata. It may appear on different parts of the body but usually al>out the trunk and on the limbs. It disappears in a day or two. A local bath of bicarbonate of soda will allay the itching.
Emollient enemata are prescribed in diarrhoeas and dysentery ; where there is much tenesmus, probably the best is that made of starch and opium. The starch is bland and unirritating, while the opium soothes the pain, not only by lessening peristalsis, but also by direct action on the end nerves. In the diarrhoeas of children more particularly, it gives ex- cellent results, but the action of the laudanum must be closely watched. To prepare a starch enema one takes a sufficient quantity of laundry starch, and adds enough cold water to dissolve it ; then boiling water is poured on until a thin paste is formed which is free from lumps. After this has been well cooked
novci ins
.65
and lias become cold the exact quantity ordered ( usually two ounces) is taken, and into it are stirred the required number of drops of laudanum. The injection is given slowly and gently through a small rectal tube.
Turpentine encmata for distension may be given according to the following formulas:
Mucilage of acacia. %s%; Spirits of turpentine, gtt.x. To be administered high up.
Nurses should be most particular about the care they take of the appliances employed in giving < ik mata. These should always be thoroughly cleaned before being put away, and this can best be done by allowing first hot soapsuds, and afterwards simple hot water, to run through the tube. The tube should always be boiled before being used on another patient. It should never be put away damp, but hung up lengthwise to drip and dry. The nozzle is to be left for some hours in a 5 per cent, solution of car- bolic acid, and then well washed off and boiled before being used again.
By a douche is generally meant a jet of fluid directed with a certain amount of force upon a limited surface, external or internal. Among those given internally are the vaginal, the nasal, and the aural douche. Douches are given for cleanliness, for thcii stimulating effects, or to relieve inflammation; like other baths, they may be cither simple or medicated The taginal •!• WT} frequently used in hospi-
tals, and is usually madi by adding some disinfectant to the water. For cleansing purposes, a 1 per cent solution of carbolic acid is often ordered; to allay
i66
AT/AW/AC
iiiflamiTialioii. a hot solution of the same strength, tli<' temperature ranging from 105" to 115' F. or even higher, can he employed. The fountain syringe with a glass douche-nozzle attached is the best instrument to use. Before the nozzle is inserted the stream of water should be allowed to flow through it until it is warm, arid it should then he introduced up toward the posterior wall of the vagina. The bag should never be more than from six to twelve inches above the recumlient patient) so as to avoid any pressure that might force the water into the uterus, the mouth of which after labor and in many pelvic disorders is dilated. The low pressure is also desirable as the flow is slower and the parts arc kept longer in a hot bath. If no special amount is ordered, a quart or three pints will be enough. The douche should al- ways be given with the patient in the recumbent position; even if she be up and about, she should be made to lie down for such treatment. The con- tinuous vaginal douche is sometimes ordered where much inflammation exists. A small hi-valve speculum is introduced into the vagina and is opened and ad- justed when aliout half way up the cavity. Around the glass douche nozzle enough absorbent cotton is wrapped to hold it in place inside the speculum. Hot salt solution is usually ordered. The douching may be continued an hour or more, and should be given under low pressure. Glass nozzles are the only ones that can be kept quite clean, and they should be of the simplest possible construction. After being used hot water is allowed to run through them, and they arc kept in a small open-mouthed bottle filled with 1:20 carbolic-acid solution, with the patient's name
CA THE T&RtiA r/o.v
i67
on the label. Each patient in the hospital requiring douches should have her own douche-nozzle. Before being used for another patient the nozzle is to be washed thoroughly with soap and cold water and boiled for five minutes in a i per cent, solution of carbonate of soda.
Betides briny u-.<-,l for giving high i-nemaia the rectal tube is sometimes inserted in order to allow the escape of gas from the bowel. In these cases the outer end should always be immersed in a basin con- taining a solution of carbolic acid. When gas es- capes it will be noticed bubbling through the fluid.
Catheterization. — As it is important for a nurse to know early in her training how to catbctcrizc a patient. the subject will be discussed here. Cystitis is an in- flammation of the mucous membrane lining the blad- der, which may be due to many different causes. One of the prolific sources of this inflammation is the introduction of foreign material into the blad- der on a catheter. If germs are introduced, the urine will be decomposed, more germs will be developed, and inflammation will result. When this is the case, the fault lies with the doctor or nurse, in most cases with the latter, since she is usually entrusted with the work. To avoid this, therefore, every nurse should make sure, when an order has been given her to catheterize a patient, that a cystitis, if such unfortu- nately should occur, will not be traceable to any neglect on her part ; otherwise she may feel that she has bees the cause of weeks or months of intense suffering to a patient through her carelessness. Let her, then, see that the utmost cleanliness is exercised. The glass catheter is by far the best for women, but, of
whatever material it be made, the instrument should be absolutely clean. The glass, metallic, or rubber catheter may be rendered thoroughly sterile by first washing with soap and cold water and then boiling in a I per cent, solution of carbonate of soda for five minutes ; it is then laid in a clean basin containing a warm solution of boric acid, where it remains until it is needed. A gum-elastic catheter should be soaked for one hour in a 1:1000 bichloride solution, then washed off thoroughly in hot sterile water, and placed in the boric-acid solution.
In preparing to catheteriie a patient the nurse is to wash her hands with soap and hot water, and after- ward soak then] in a I :iooo bichloride solution. She then takes sUnli/ol gauze sponges, forceps, the basin with the boric solution and catheter, a vessel to re- ceive tb£ urine, and some sterilized oil. The patient lies fla'i on the hips with the knees somewhat separ- ated ; a sheet or blanket is next thrown over each knee, leaving the vulva exposed; this is necessary, as one mvft see that the parts are clean. In bathing, gauze sj'ongcs should be used to separate the labia, and the region of the meatus urinarius should be carefully washed off with pledgets of gauze held in the forceps and soaked in the boric-acid solution. The catheter is then lifted with the forceps and the nurse, holding it by its outer end, introduces it into the urethra, taking care to touch with her hands only the portion which will be left outside. With a glass catheter no oil is necessary.
The urethra is situated just above the vaginal out- let, and as a ruic can be easily seen: the end of the catheter should enter the bladder quite readily. If
6LAnnF.lt- WASHING
169
any obstruction be met with, the instrument should not be puttied forward, but withdrawn slightly and its course changed. If the urine ceases to flow, the catheter is to be withdrawn 3 little or the position changed, when it may flow again. If the bladder is very much distended, it should not be emptied en- tirely the first time. When removing the catheter the finger should be placed over the end, so that any drops of urine remaining in it may not fall upon the bed. After the urine has been drawn off the part) arc bathed and dried. Hot water is passed freely and with some force through the catheter. Glass catheters may be boiled in soda solution, and then kept in a 5 per cent solution of carbolic acid. The others, after being thoroughly washed and dried, are laid aside, folded in a clean towel, and must be steri- lized in the manner described above before being used again.
If a specimen of urine be required for examination, it should be drawn directly into a sterilized bottle, the top of which is to be plugged with clean cotton. Otherwise a patient should not be cathctcrizcd unless absolutely necessary.
For irrigations of tht bladder various solutions are ordered. The warm solution is poured into a sterilized rubber bag or fountain syringe. The catheter having been introduced and the urine drawn off, the end of the conduit tube from the bag is attached to the end of the catheter and the solution is allowed to run slowly into the bladder, the stream being controlled by pinch- ing the tube. After about two hundred cubic centime- tres have run in, or sooner if the patient complain- i>i pain, the tube is disconnected from the end of the cathc-
170
NURSING
tcr and the bladder allowed to empty itself. The pro- cess may be repeated several times, until the washings are clear. If desired a two-way catheter may be em- ployed, especially if the distention of the bladder is at all painful.
A very simple and convenient apparatus consists of a glass funnel with rubber tubing connecting it with a glass catheter. All these articles can be sterilized by boiling in a I per cent, solution of sodium car- bonate. After the urine has been drawn off. the air is expelled from the tube by allowing a small amount of the solution to pass through it; the solution is slowly poured into the funnel and passes into the bladder which is gradually distended. The funnel is then inverted below the edge of the table and the fluid is siphoned out. This procedure is repeated several times. A* now practised in some hospitals the process is very simple, a silver "two-way" catheter being used. It is shaped somewhat like the letter "y" — the long arm for insertion into the bladder, and the upper arm attached to the tubing of the bag, so that they arc connected and boiled together. The channel of the catheter is divided lengthwise, and has two holes near the inserted end, so that the irrigating fluid flows in through the upper short arm and one side, and returns by way of the other side and the lower short arm. In this way a continuous irrigation is kept up with no necessity for interrupting the flow.
CHAPTER IX.
Temperature. — Pulsr— Respiration. — Care op thb Ther- mometer— Charting and Recording Note*.
The temperature, pulse and respiration in health bear a certain ratio to one another, and any vari.it Eon in one will usually be found associated with changes in one or both of the others. Thus it becomes neces- sary, when considering the condition of one, to bear in mind at the same time that of the other two. A knowledge of the functions of the skin, of the circu- lation of the blood, and of the chemical changes that take place in the body and produce heat, is necessary for a full comprehension of the establishment and maintenance of the bodily temperature, by which wc mean the degree of heat found in any part of the body. This is nearly equal everywhere, since the blood which penetrates all portion of the system has for one of its functions the general distribution of the heat. In health the temperature varies constantly within certain narrow limits, although a normal tem- perature by no means indicates that a person is free from disease. The normal temperature of the human body is 98.60 F. (22° C.), but under certain circum- stances may he anything between 97.5 ° and 99.5* F. A temperature above or below these points is to be considered abnormal, that is. as denoting a depart* in* from that of the normal or healthy condition. The normal variations may be classed under three different
headings :
in
1 7- NURSING
First: tboa dependent upon the time of day at which the ii -iiiiii-i.il; ik is taken, as definite daily cfaangei take place within the Limits mentioned above. During the greater part of the day about the mean temperature of y8.6: V. is maintained, but by four or clock in the afternoon this is found to have in- creased to 99 ° F., or may even be a little higher; at light o'clock in the evening the fall begins, which con- tinues until the lowest point, 980 or 97.5' F.. is reached by 2 a. m. The temperature may continue low until between six and seven o'clock, when it again rises to 98.6* F. Tncsc fluctuations arc easily accounted for, since during the day food and exercise tend to gradu- ally elevate the temperature slightly, while after eight o'clock in the evening, when there is rest of body and mind and the hours are passed in fasting and sleep, there is naturally a slight decrease. In young children and the aged the diurnal variation is greater than in adults.
Secondly : those dependent on the part of the bodg in which the temperature is taken; thus the tempera- ture in the axilla is always lower than that of the mouth by three-tenths of a degree, while that taken by the rectum is half a degree higher than that taken in the mouth.
Thirdly: those dependent on other causes. Thus the ingestion of highiy-seasoned, stimulating foods elevates the temperature. Again, certain general or local causes may exercise a decided influence on the heat of the whole or of certain parts of the body; for instance, profuse perspiration reduces temperature, or if the hands and arms arc dipped in cold water, while
THE TEMPERA TURF.
'73
the axillary temperature may be subnormal, that taken
fay the mouth may give a normal reading.
Any departure from the normal temperature, beyond certain limits, indicates a deviation from health or the invasion of disease, and in many instances the inti n n\ of the morbid process is directly proportionate to the elevation of the temperature.
Abnormal temperatures arc recognized as (l) sub- normal, (2) elevated. A subnormal temperature n: >•. range from 96* to 98* F. In conditions of collapse it may go as low as 95° F., but this is extreme, and there i* little hope of a patieni rallying with such a temper- attire. A genera] depression of the vital forces may produce a subnormal temperature, or local causes — e, «. traumatism by producing shock — may have a similar effect. In paralysis, after -.evcre hemorrhage. in some diseases where there is a continual ii waste going on, in chronic malaria where the blood has been much impoverished by the malarial organ- ism, in some nervous disorders, and in certain poison- ings that affect the heat centres and in heat exhaus- tion.— in any of these condition* there may be a sub- normal temperature.
An elevation of temperature means excess of heat in the body, due cither to an increased production or to an over-accumulation from imperfect dissipation.
The range of temperature compatible with life may I pi fairly placed between 95° and 1090 F., either of these extremes usually being a fatal symptom. In some extraordinary cases, however, in which there were remarkably high or low temperature.*, recovery has ultimate!) taken place. We may then classify the temperature conditions as follows:
1 74 NURSING
Temperature of collapse Q5°-97* F.
Subnormal temperature 97*-98° F.
Nonas] " . .98-6" F., with variations.
Subfebrile " 99$'-«oo.5° F.
Fever of moderate degree too.5°-io3° F.
Btgtl fever IO,J0-I05* F.
Hyperpyrexia 1... above 105° F.
The temperature should be taken at least twice a day, owing to the diurnal variations; thus, a morning temperature mav be normal, while the evening tem- perature may be considerably elevated. The instru- ment for measuring the heat of the body is called 1 clinical thermometer, to distinguish it from the ordi- nary instruments. The Fahrenheit scale is the one principally used in America and England, but the hidex range extends only from 950 to no*; each de- gree is divided into five equal parts, each of which represents two-tenths of a degree. The normal point is marked by an arrow. On the continent of Europe the Centigrade and Reaumur scales take precedence.
The rule for converting Fahrenheit into Centigrade degrees is to subtract 32, multiply by 5, and divide by 9. For instance,
I04°F.= [( 1040 - 32°) X *] C- 40°C.
To reduce Centigrade to Fahrenheit multiply by 9, divide by 5, and add 32 to the result.
Thus,40°C.- [(400 x|) +320] F.-io4°F.
To reduce Fahrenheit to Reaumur subtract 32, multi- ply by 4, and divide by 9.
/The instrument should be accurate, self- registering, and clearly indexed. A Hicks' thermometer, with a
1
THE TEMPERATURE
'75
Kew Observatory certificate, is very good, but ;iU thermometers change with age, and should be tested by a standard frequently and the necessary corrections made. The best way to test a thermometer is to place it, along with one of known accuracy at the same mo- ment, in the mouth or rectum. After these two have been left long enough to register, they are taken out together and the results compared. Ileforc being in- serted the mercury should be shaken down below 950 F. on the index. The temperature may be taken cutancously between two folds of the skin in the axilla or groin, or in sonic of the cavities of the body. the mouth, vagina or rectum. The length of time necessary for obtaining the registration depends upon where the temperature is taken and upon the ther- mometer used. None register under three minutes ex- cept the special one-minute thermometer, which is too expensive for hospital use and not always trust- worthy. The time allowed for registration in the mouth or rectum is from three to five minutes. The axillary b UM Will be from one-tenth to three
tenths of a degree lower than that taken by the mouth. The rectal temperature is the most accurate, as by this method the patient is not required to assist ; in- deed, for children it is the only one reliable. Precau- tions must be taken to have the rectum free from faeces. The bulb of the instrument is to be oiled and inserted gently for about one and a half inches: to prevent SCCldentS the nurse usually holds the stem. The only disadvantage lies in the inconvenience of the procedure. unl< d there be any disease of the
parts, since an elevation might then l>e <h\e merely to local causes.
i76
HV/tSING
For obvious reasons, however, the temperature is most commonly taken by the mouth. The ther- mometer should be placed under the tongue, the pa- tient being instructed to breath through the nose, to keep the lips tightly closed over the instrument, but not to bite it. If the lips be dry, they should be moistened, but one should be careful not to take the mouth temperature directly after a hot or cold drink. If a patient is too weak, or the lips tod BKHttfa are so dry that they cannot be kept tightly closed, air will be admitted and the record will be inaccurate. More- ihe mi thod is not a safe one for very dull, un- conscious or delirious patients, since they may bite off the bulb and swallow it. Should this accident hap- pen, it should be reported at once to the ph> though as a matter of fact he can do nothing, and the results arc not likely to be serious. In several cases which I myself have seen, and which were left to nature, no harm resulted.
In taking the axillary temperature the arm-pit should be wiped thoroughly dry from perspiration ami the thermometer placed in the hollow: the arm is then held closely to the side with the elbow flexed and the hand renting on the opposite clavicle. If the patient is very weak the arm should be held in place by the nurse. Sometimes there is too much emaciation to admit of the close contact of the skin surfaces: in such cases or where there is excessive perspiration an axillary temperature should not be relied upon. The method is convenient at night, since it can be practised with but little disturbance to * sleeping patient, win h- U if the temperature is taken by mouth when half asleep he is liable to allow the lips to open. In re-
THE TEMPERATURE
•77
cording a temperature one always Mules win n [| nil been taken. Tlie temperature should not be taken just after any exertion or after a bath, unless the latter has been given for fever.
Before using the same thermometer for another pa- tient the nurse should be particular to soak it for three minutes in a I :looo bichloride solution and rinse it off in clean water. When thermometers arc not in use they should he kept in a glass filled with a fresh solu- tion of bichloride of mercury (i :iooo). the bottom of which is covered with absorbent cotton as a soft I" d for the mercury bulbs to rest upon.
It is an excellent thing to learn to judge of the con- dition of a patient's temperature by the touch, training the fingers or hand to feel differences, and controlling the impressions thus received with the results obtained witli the thermometer, since the attention of a MUM with a well-trained touch may sometimes be drawn to an unusual condition in a patient that otherwise might pass unnoticed. It should be remembered, however, that the surface temperature is not a reliable index to the general bodily heat: the skin may feel compara- tively cool when the thermometer in the rectum shows an elevation of several degrees.
The thermometer is of great value in diagnosis, and in any doubtful case the temperature should be taken at short intervals until othersymptomsniamt. m them- selves. In hospitals one occasionally meets with a malingerer who, if not watched, will put the thermo- meter near a hot-water bag or in other ways produce an unaccountably high record, With children a high temperature is not necessarily so serious as the same
would be in an adult. In hvstcria the temperature u
i78
tfU#S/JVG
may reach 104" or 105° F., and then fall without a recurrence. This, however, is of very rare occur- rence.
In recording a temperature or pulse, where any doubt exists as to the accuracy of the observation it it advisable to place a question-mark ( ?) after the record, in order that the attention of the physician may be called to the possibility of an inaccuracy. But ex- tremely high temperatures are possible. These are in- stances of the so-called "paradoxical" temperature, and arc more likely to occur just before death. Observers whose reliability cannot be called into question have reported temperatures (in the last stage* of disease) as high as H2C F. In sunstroke 109* F. and even higher temperatures have been recorded. Hilton Fagge cites a case of a young woman (observed by Teale) in which on four different occasions the mer- cury was buried in the bulb at the top of the ther- mometer at a point above 1220 F. Whenever, how- ever, the thermometer registers an extraordinary temperature (whether above or below normal), the results should be controlled more than once, and sev- eral different instruments should be employed, before we arc convinced that no error on our part has been made.
tr is present in almost all acute infections: it is not a disease in itself, but a symptom. The progress of a disease may oftentimes be estimated and indica- tions for treatment may often be obtained by watch- ing the course of the fever.
Fever or pyrexia may be classed as continuous, re- mittent, or intermittent. A continuous fever is one in which the temperature is uniformly above the normal
FEVER
179
line with but slight variations, such as is seen in pneu- monia. In a remittent fever there is a rise ami fall as in typhoid fever, although the temperature never reaches the normal line. In intermittent fever the temperature is high, but at some time during the twenty-four hours drops to the normal line or even below it, as in tertian malarial fever.
A febrile temperature may fall by crisis or by l\ By crisis it drops suddenly to the normal, as is usual in pneumonia, while by lysis the fall is gradual, as in typhoid fever. A convalescent- temperature may be influenced by apparently trivial causes, such as slight over-exertion, a change in the diet from light to more solid food, or by excitement of any kind. A sudden and decided increase generally indicates some com- plication, and the doctor should be informed at once; in fact, any rise of temperature above 1030 F. should be reported. More than this, a sudden drop from a high temperature to a subnormal point (unless in pneu- monia) most probably indicates collapse, and the physician should be notified.
Before death the temperature in fevers may be very high, while in chronic malignant diseases and cachex- ias it may be subnormal.
Charting temperatures should be done with nc.n and accuracy : one nurse at a time should be set apart to take temperatures and pulse-rates and record the same for the whole ward.
The lines should be lightly and evenly drawn, the ;it which the temperature Mands being indicated by a small (not too heavy) dot. The night and morn- ing records are best done in black, while the tempera-
A'LWSAYG
tures taken in tin* intervening hours may be marked
in red ink.
The so-called tcmpcraturc-curve formed on the chart by means of connecting lines instead of bj a series of numbers is often so characteristic as to be of distinct assistance in diagnosis. It may be studied on the 24-hour chart in three sections, the onset, the height, and the decline.
The chart for a new patient should be headed with the patient's name, date and hour of admission. The diagnosis can be added later. The pulse, temperature and weight on admission should then be charted. Only temperature, pulse and respirations that have been carefully taken should be recorded. Any other ob- servations are noted in the hourly record sheet.
A patient should not have access to his chart, nor is it right to keep him informed of the course of his temperature, since it may have a bad effect upon even the most sensible penoil to know that his fever still continues high.
The specimen chart* of typhoid fever, pneumonia, and malarial fevt-r given at tin 1 nd of this chapter, and taken from actual cases, show the variations and dif- ferent types of tem|K-raturc in those diseases, and also the method of charting (Plates III, IV and V). Plate VI is an example of a bedside record.
The Pulse.— The examination of the pulse is an im- portant guide to the patient's condition, since from it one may draw conclusions in regard to the strength and action of the heart. One of the most difficult things a nurse has to learn is to count the pulse ac- curately and to understand its variations and their significance. This requires much practice, and the
THE PULSE
■ Si
proper skill can only be acquired by nincb persever- ance and close study. She should begin by counting tli<' pulses in normal case- until she I thorough
ly acquainted with the characteristics of the healthy pulse and whenever she has an unoccupied moment she should count the pulses in various patients and note their differences and |Kcnliaritiev When she has heard the pulse of a patient described, she should examine it repeatedly until she feels that she could recognize another like it. Frequently it is neces- sary to watch the pulse of a sleeping patient: this should be practised until it can be done without dis- turbing the sleeper.
The pulse is dependent upon the rhythmical con- traction of the heart. With each heart-beat the blood is sent through the arteries with more or less force, distending the arterial walls, ami it is the sudden ex pansion of the artery, felt under the fingers, that we call the pulse. This distension takes place only during the systole or contraction of the heart, and the diastole Or period When the ventricle is filling with blood is represented approximately by the interval between two pulse-beats. An artery can be recognized by I In- intermittent poltttlen in it and by the elasticity of its walls. The rise of the pulse-wave is clearly defined, but can be arrested in normal cases by firm pressure made with the fingers. The points to note in taking the pulse arc —
1 . Frequency ;
2. Rhythm fof irregular force) ;
3. Whether or not it Es intermittent;
4. Size of artery ;
i8i
NURSING
5. Degree of distension between the beats, if any exists, 0. The character of the pulsations —
(a) Whether the rise is sudden or gradual;
(b) Duration of impulse — long or short ;
(c) Fall — abrupt or gradual ;
(d) Dicrotism;
7. Compressibility —
(a) Low tension ; (hi High tension ;
8. Thickening (atheroma) of the vessel-walls. The character of the pulse depends upon the action
of the heart, the condition of the arteries, and the amount of resistance in the capillaries. The action of the heart determines —
( 1 ) The frequency of the pulse ;
(2) Its rhythm and regularity;
(3) Its force and strength.
By frequency is meant the number of beats in a given time. The normal number of beats in a minute varies in different people, ami the pulse is slower and stronger in men than in women, and in women than in children. The blood-pressure is determined by the force of the heart and the resistance in the arterial and capillary circulation.
The average pulse in Men is from 60 to 70 Women " 65 to 80 \f Children " 90 to 100-120
The normal pulse is recognized by —
( 1 ) Its perfect rhythm ;
(2) The eqn.il force of successive heart-beats;
(3) The medium size of the artery,
THE PULSE
'83
The pulse is usually taken at the wrist, where the radial artery is easily felt pulsating because it lies directly over a bone and is superficial. The index and middle fingers arc placed over the artery, pressing firmly enough to feel the beat. One counts usually for half a minute. After long practice it is possible to count accurately a pulse as frequent as too. It is sometimes more convenient to take the pulse in the temporal artery.
The normal pulse may be affected by the same causes which produce variations in the normal tem- perature. Its frequency is increased by —
(a) Food or exercise. The pulse will be fuller and more forcible, and the vessels of the surface are re- laxed.
(b) Excitement. It is quickened, but the accelera- tion lasts only while the excitement continues. Stim- ulants accelerate the pulse slightly and relax the super- ficial vessels.
(c) Position. The rate is higher when the patient is standing than when sitting or lying down.
It should be noticed whether the pulse at both wrists is the same, as the volume or frequency of one is sometimes greater than that of the other : in aneur- ism there may be almost complete obliteration of the pulse in one wrist. One will be startled at times, on feeling for the pulse of a newly-admitted patient, to find absolutely no pulsation over the spot usually pal- pated. Tin's is frequently due to an anomalous distri- bution of the vessels in one arm or to a previous injury which has severed the radial artery on that side.
In illness the pulse indicate* the effects of the dis- ease on the system and the existing amount of endur-
Il4
XUKSLVG
of t lie most marked differences be- lli, pulse in health and in disease is that in the there i* an increased susceptibility to the same 1 1 cause variations in health. In most ri the pul* i accelerated, and the more frc- ili, number of beats the weaker, as a rule, the , ,ii. In II, to express the quality of the pulse. .,.1 l.i.v," "strong" and "weak," are vague, exprc*»ions, as quick or slow might refer I., ili. i n ill <»f each beat or to the rate at which the folio "'<• another, and strong and weak are i I. i. We use the term frequent for a pulse ii|. |o If0 '" 115: a pulse of from 115-140 we call fHfUl n |ml«r >»f from 140 and upwards we call
W. IpCth "f a pnlM l)cing long or short when de- ll Individual pulsations. The terms forcible. > I li< mi hi, sluggish. 01 feelile, arc also used to express I here are several different types M a pulse may be— 1 In. (either in force or in sequence);
[nisi mittenl ;
hi mm irregular pulse the beats differ in length, force
1. iy apply to the strength 01 ili ihrn '" to bofli An intennitteot or an lrrtj(iiliir pulM dhj bi Induced by —
1 l in 1 audition <<< ihfl heart or respiratory organs. >i nle iIim j»e. when it may he a grave symptom;
1 f I hi 11 ' •• OUS S) -tern.
vviui. ii" pul 1 Ii Intermittenl .1 best 11 toel from
.i.-, Win. 1. curs, as it sometimes does,
THE PULSE
,«s
in health the causes are not fully understood. The condition may be brought on by nervousness or ex- 1:... -linn.
A dicrotic pulse indicates a relaxed condition of the arterial system, and consists of one beat followed by a second, which is in reality a wave in the blood-current produced not by another contraction of the heart, but by the closure of the aortic valves. This secondary pulse-wave is usually less forcible than the first, but sometimes resembles it jo closely as to be counted as an individual beat. Medic.il students and young nurses, b counting a pulse of this kind, sometimes obtain a result exactly double the actual nnml>er of heart-beats. The error becomes at once apparent if one hand be held over the point of maximum impulse of the heart on the chest wall while the other is at the wrist. A dicrotic pulse is found frequently in the acute fevers, particularly in typhoid fever.
Tin- tension of a pulse is determined by the degree of resistance which the artery offers to the pressure of the fingers, and the terms used in this connection are "high." and "low;" if the resistance is considerable, WC lay thai the tension is increased or that it is plus (T-| ) ; in the opposite condition we have a deer 01 minus tension (T — ).
The remote causes of high tension are —
I, Excess of animal food or alcoholic drinks.
a. Sedentary habits with the resulting imperfect oxidation.
,J. Constipation.
h ' nakm may be present as a result of obstruc- tion in tin- arteries or capillaries, caused by—
/ft -A'S/XG
hauye* in tl walls or deposits of lime
* ^ >ns;
isc of the heart or kidneys; KfOttk lead-poisoning.
here is a pulse of high tension in
[Ulofl ptllM the arterial tension is dimin-
weakened condition of the heart or
.1 mute of the peripheral vessels, and the
dn» easily compreaaible: it may have the
h1 full, but this does not always i iv and strongly-beating heart. In ivii,i • where the heart is very weak and the i Uxl rnt nut with each systole is small, the
ri I) comprecsible, and we have what I. the running ptil-i . low tension may be i i fever, prolonged exertion, mental or I ' rtain conditions of the nervous
i\ li 'in tl rfstfc >>f a high arterial tension
lb in\ of the pulse-wave; the artery
ihi lull lieiwe-en uul may be rolled
ngci like a cord. The pulsation for this
i| In mtv marked, and may convey the
'' the pul« El n. •! strong, but on cxami-
ill !.. I ml to resist more strongly the
I i In- immediate causes of this
i i in n il" force of the heart's beats;
|, t\\ i llie smaller arteries (<•. g. from
f cold to the external surface of the
ftF.SPIRAT/ON
.87
One should be very observant of the effects pro- duced upon the pulse by therapeutic measures. In giving medicines which affect the heart any difference in the pulse before and after administration should be carefully noted. If a hath is ordered the pulse should be watched closely. Stimulants increase the frequency of the heart's action, while antipyretics have a depress- ing effect.
A persistently slow pulse is often observed in men- ingitis, cerebral tumors, in certain forms of drug poi.-.- Oiling, and sometimes in convalescence, especially after influenza.
The ratio borne by the pulse to the temperature and respiration is of much importance. If a pulse is more frequent than the temperature would lead us to expect, this is usually an indication of a weak heart, and the weakness is, as a rule, in proportion to the deviation from the normal ratio of pulse to temperature.
The Respiration. — External respiration is the act of taking in and giving out air by tfae hmgs. This per- mits of the interchange of gases in the lungs, the blood in the small capillaries being separated from the air by an extremely thin membrane. The venous 1,1. h m I brought to the lungs by the pulmonary artery is oxygenized, and returns through the pulmonary veins to the left heart as bright arterial Uood. The average unrulier of respirations to the minute in an adult is eighteen, in a child from twenty to twenty-four. Any marked variation from this is abnormal. A - breath consists of two parts, characterized by the al- ternate expansion and contraction of the chest; with dilatation we have inspiration : with contraction, ex- piration. There arc normally four lieart-bcats to one
188
NUKS/XC
respiration. In <li K9. ■-• there arc marked variations in i lie character of the respiration. The breathing is slower and shallow in narcotic poisoning, shock and collapse. On account of pain it is restrained in pleur- isy and peritonitis ; it is shallow in ascites, abdominal tumors and advanced pregnancy. In cerebral haemorrhage the cheeks arc puffed out with each breath. In some diseases such as peritonitis and pnen- monia. the respirations may be very rapid ; when they number over forty to the minute this symptom is con- sidered grave. There are cases, however, in nervous and hysterical patients where the respirations may be exceedingly rapid, perhaps over sixty to the minute. in vim pulmonis) diseases tin- respiration may often be out of proportion to the pulsc-ratc. The same ex- citing causes which affect the normal pulse and tcm- jieraturc apply equally to the respiration. Not only are the rate and general character of the i to be noted but also the effect exerted upon it by posi- tion, and the way in which the two sides of the clll U move. In making a record of the respirations one should note —
I. The frequency; 2. whether regular or irregular: 3. whether difficult or easy ; 4. noisy or quiet ; 5. deep or shallow: 6. the symmetry or asymmetry of the chest and its movements; 7. the type, abdominal or thoracic.
Stimulants accelerate the pulse slightly and relax the superficial vessels.
In some affections, such as asthma and heart disease. there is dyspnoea— that is, difficulty in breathing— and a sitting position is the most comfortable. In heart disease when the lungs become engorged with Mood owing to defective circulation, the breath conies
RECORD OF TRE.-IT.%fF.XT
189
111 short gasps, and the condition is not only dangerous inn very distressing to the on-lookers.
The most peculiar type of breathing is that found in the dyspncea of certain diseases of the heart and kidneys, known as Chcyne-Stokcs respiration. There is an increase in the frequency and intensity of the respirations up to a certain point, then a gradual de- crease until they entirely cease for several moments, when the cycle is repeated. Sometimes in affections of the lungs the movements associated with the thoracic breathing arc limited to the upper part of the chest. When the abdominal walls are sucked in with each Inspiration the condition is grave.
Stertorous breathing is characterized by a loud snoring sound with each inspiration. The stcrtor is due to paralysis of the soft palate causing it to hang down and obstruct the free exit and entrance of air to the lungs. The symptom may often be relieved by propping the patient on his side.
In taking the respiration one must not allow the patient to be aware of the fact, for he will uncon- sciously control it. After taking the pulse the fingers may be left on the wrist, and while the counting is apparently continued the rise and fall of the chest may be noted. In some cases the exact rate can be de- termined correctly only during sleep.
At times the breathing is so bad that the patient cannot assume the recumbent posture at all — a condi- tion known as orthopnea. The car should be trained to detect differences in breathing, so that even in the dark the slightest change may be at once noticed.
Record of treatment. In diseases where changes in treatment arc few. as in typhoid fever, a brief note of
_
190
XUKS/XC
the various procedures can be made on the tempera- ture chart (sec specimen chart). After operations, however, particularly after abdominal sections, and in certain diseases where the treatment varies every few hours, a bedside or hourly record-sheet should be kept, each step of the treatment being neatly and accurately put down by the nurse. Such notes should contain a simple and concise statement of the treat- ment given and the developments throughout the course of the disease. Such a sheet should not be arranged for more than twenty-four hours, so that at the end of that time a summary of the whole condition can be given. The physician on his morning and evening visits will then be able to see at a glance just what has been done, without having to listen to a detailed report before the patient. The temperature should never be reported to the physician nor the symptoms discussed in the presence of a patient : if it is necessary to sec the physician alone for a moment,
tin rmiM should iiy to do n outride the roon dther
before or after the visit, though, as a rule, the record should be clear enough on all points to fully explain the case.
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CHAPTER X.
External Applications (general and local) —Dry Heat.— Hot-water Bags and Cans— Hot Bottles, Flannels, Salt-bags.— Moist Heat.— Fomentations.— Poultices.— Moist-air Tent. — Cold Applications.— Ice. — Colo Wa- ter.—Lotions.
External heat, whether applied generally or locally, is intended to give additional warmth to the body, t<>
allay inflammation and relieve pain, to promote suppu- ration, or to act as a diaphoretic. Cold applications are used chiefly to reduce temperature am! inflamma- tion, but sometimes also for their stimulating effect.
It is a matter of every-day experience that warm weather makes itself felt much sooner and more se- verely when die atmosphere is saturated with moisture than when it is dry. Just in the same way hot moist applications have a much more marked effect and are more depressing than dry heat at the same tempera- ture.
Dry heal when required for its general effect is ob- tained by means of the hot-air bath, which is often Ordered when the kidneys arc failing to <1«> their work well: the waste products, not being excreted in the normal amount, are accumulated in the system, and the hot air. acting upon the bodj by dilating the superficial blood-vessels, produces copious perspira- tion and brings about in this way the elimination Of much of the poisOOOtM material, The method is described in the chapter on Baths.
m
DA' Y /IE AT
'93
When dry heat is applied for the sake of warmth alone, it is best to use hot bags, bottles, or cans. Such bags are made of india-rubber and are of different shapes and sizes. They should be filled not more than about half full of hot water, for when quite full they would be heavy and difficult to adjust: before the top is screwed on the air must, as far as possible, be expelled. Hot-water bags must be watched, as they arc liable to leak and make the bed wet, if the top be not tightly fastened.
Except for applying heat to flat surfaces, such as the >idc of the face or abdomen, hot-water bags are not so serviceable for hospital use as the hot-water tins, bottles or bricks. In using tin cans particular care must be taken lest the patient be burned: they are especially valuable in warming the bed for an operation patient, but on no account should they be lift betide an unconscious patient unless they can be constantly watched. In invalids the vitality of the tissues is lowered, and it is an easy matter for them to sustain a burn which in their case may prove very troublesome, though in a healthy person it might heal at once. This is especially true of paralytics. Hot bottles are not very safe, as they are apt to crack or burst. If they must be used, they should be placed with the corked end away from the patient, and should not be filled more than two-thirds full. The chief recommendation of bricks is that they retain the heat a long time; on the other hand, it may be objected that they are uncleanly and clumsy. As in the case of the hot-water bags, these cans or bricks should be pro- tecte<l with i i < made of ordinary flannel or of canton flannel, and placed in the bed with a blanket between
194
VI RS/ttG
them and the patient. These appliances are used in the warming of beds for operation patients, for cold extremities, for pain, during a chill, in cases of col- lapse or shock, or for very ill patients in the early morning hours.
Hot flannels arc sometimes ordered for inflamed joints and abdominal pains. The flannel should be made very 'hot, wrapped in a heated paper or cloth, and applied quickly, the whole being covered with a layer of cotton-wool and oiled muslin. Salt-bags are used for the same purpose, for neuralgias, and more especially for earache. They are simply flannel bags filled with sea-salt, heated just as hot as can be borne, .iml covered with cotton-wool and oiled muslin. They retain the heat a long time, and are very soothing. In earache competent authorities recommend the use of the so-called "Japanese hot box."
Dry heat at high temperatures is employed as a therapeutic agent in chronic gouty or rheumatic af- fections, arthriti v deformans, gout, sciatica, lumbago and other condition!. For this form of treatment special kinds of apparatus arc found in many hospi- tals; but owing to the cost and bulk and because the treatment when properly given consumes a good deal of time their use is largely confined to institutions. The usual temperature at which the hot air is applied to the whole of the body, exclusive of the head, ranges between 220° and 280* F., but for the limbs it may be U high as 300* or even 3800 F.
Moist heal is more penetrating and has a more pro- nounced effect than dry heat. It is applied in cases ■ if muscular spasm, tinoc !■)' dilating the superficial blood-vessels it relaxes the tissues, quickens the cirai-
MOIST HEAT
•95
lation in the affected part, and by ilrawing the blood to the superficial vessels relieves the tension of those more deeply seated, and thus eases the pain. Moist heat is better in unite inflammations that can not be prevented from going on to suppuration. The applica- tions should be as hot as can be borne. They hasten suppuration In in, and piimoting the activity
of the leucocytes or white blood-corpuscles, the relaxed condition of the blood-vessels, caused by the heat and moisture, perhaps facilitating their escape through the walls of the vessels.
For a general systemic effect warm tub-baths are ordered: they relax the muscles, relieve nerve-tension, equalize the circulation of the blood, and induce sleep. For sleeplessness they should be given in the evening after all arrangements for the night have been made. so that the patient will not again be disturbed. The vapor bath is another method of applying heat general- ly, and is used for the same purpose as the hot-air bath. For localized pain, fomentations, stupes, and poultices of various kinds are prescribed, their action being precisely the same, since they relieve pain and inflammation by dilating the blood-vessels in the neighborhood of the painful part. Poultices or cat* plasms arc best used in cases of deep-seated pain or continuous inflammation. They may be made of any non-irritating substance which will hold and convey moist heat, both of which conditions arc fulfilled by linseed, which is perhaps most commonly used. To make a linseed poultice the meal is stirred slowly and evenly into water which is already boiling: the mixture is then boiled for several minutes, being stirred briskly all the time : when thick enough it is beaten well with
•96
SUXS/XG
_s
a spoon xa order to remove the lamps and to porate into it a certain amount of air. which win make it light. If wefl beaten and boiled, it • ill make a light smooth paste, just stiff enough to drop away from the spoon. A layer half an inch thick is spread on a piece of muslin or coarse cloth of the required size, a margin of an inch being left to be turned in; the surface is vaselined and covered with a layer of thin gauze ; the edges are turned over and the whole is covered with a rubber cloth or rolled in a towel to keep it warm, and carried to the patient The spreading of the poultice is facilitated by the use of a thin piece of board — a "poultice board" — upon which the cloth is laid. One poultice should never be re- moved until another is ready to be put on. Before it is applied the skin is to be wiped dry. Oiling the |Kiuliicc with vaseline prevents irritation of the vkin and the formation of papules. The poultice when in place should be covered closely with a layer of cotton- wool and oiled muslin to prevent the escape of the heat and moisture. It must be changed at least every three hours, and where it is desired that a uniform temperature be maintained it should be changed oftcner — every hour or so. A poultice should be applied as hot as the patient can bear it: it should ft on until it becomes cold, and should never be reheated and used again. Bread poultices are sel- dom used, as they retain the heat and moisture only a very short time. They are made by pouring boiling water over the soft part of the loaf. The vessel is put over the fire until the bread is thoroughly soaked. The water i'. then poured off and tlic mass is beaten quickly with n fork, after which it is ready for use.
rOULT/CES
'97
Linseed poultices are sometimes ordered to remove sloughs from a wound, and then arc best made with 1 140 carbolic-acid solution, which is also slightly stimulating and destroys odor. They are not so useful for this purpose, however, as gauze wrung out of a 1 per cent solution of carbolic acid or a saturated solution of boric acid, laid in light fluffs against the parts and changed frequently. If poultices are ordered for such a purpose, they should not be left on after the slough has come away. One sometimes sees them used until the granulations and surrounding tissues look pale and flabby, a condition which indicates a lack of vitality due to too much moisture, the tissues hav- ing become water-soaked. Charcoal as a deodorizer is occasionally ordered where there are sloughs which give off an offensive odor. One part of powdered charcoal is mixed with two parts of linseed, and the poultice made in the usual way: before applying, it is well to sprinkle a little charcoal over the surface. The application, however, is a very untidy one. and for this reason is seldom ordered. On the other hand, gauze dipped in a saturated solution of permanganate of potassium makes an excellent deodorizer.
A starch poultice on account of its soothing prop- erties is used in skin diseases where there is much irritation. The starch is mixed first with a little cold water, and then enough boiling water is added to make a thick paste, which is then spread on muslin covered with a layer of gauze. If there be a great deal of pain, a few drops of laudanum may be sprinkled over the surface just before the poultice is applied.
The jacket poultice — sometime* ordered in lung af- fections— is made as follows: Two layers of thin
„«
NUNSING
muslin arc shaped so as to fit closely around the neck and under the arms, and come over the chest and back low enough to cover the lungs. Three sides are now closed and the prepared linseed is poured into the hag and properly distributed. The open end is then closed and the jacket is applied ; over it comes a cover- ing of wool and oiled silk, and the whole is kept in place by means of safety pins or tapes which arc tied under the arms and over the shoulders. In changing such a poultice care must In- taken not to expose the patient. For a few days after it is discontinued a cotton-wool jacket must be worn.
To make a mustard poultice, take of ground mustard from one-eighth to one- fourth of the amount of meal used. Make into a paste and stir this into the linseed after it has been prepared for the poultice. Yeast poultices arc often ordered for their stimula- ting effect for ulcers, gangrene and sloughing condi- tions. They are prepared as follows: Mix eight ounces of soft yeast with a similar quantity of water. Add enough flour to make a sponge, but not too stiff. Keep in a warm place until fermentation has begun; then apply daily. Giarcoal is sometimes added to these applications. For the soothing effect, hop-bags or bran-bags dipped in hot water may be applied, pro- tected and kept in place with a firm bandage.
The most pleasant way of applying moist heat is by means of fomentations, but they are somewhat trouble- some, as they require to be changed very frequently. Where heat is the first requirement, a change is neces- sary every ten or fifteen minutes, hut if they are used principally for their moisture, about every twenty minutes. In no case should they be left on until they
STUPES
199
arc cold and clammy, and in fact, unless very thoroughly applied, fomentations do little or no good. The most suitable materials are sheets of lamb's wool. The layers of wool arc cut into the size required ami encased in a gauze cover over which is put a layer of oiled silk. The wool makes a very light and dur- able stupe and one that holds the heat a long time. If tlie wool is not obtainable, coarse old flannel old blanket will answer excellently, as the fibres arc thick enough to retain the heat for some time, while
STUrcWtiaoti.
ill BWfKoi are coarse enough to allow the circulation of warm air through it. Two layers of flannel arc taken, dipped in boiling water, and lifted into the wringer. The latter is made of a stout piece of tick- ing 18 inches long and 15 inches wide, with a hem at each end through which runs a stick. Another form of ''stupe-wringer" may be made according to the figure here presented ( l**ig. 5). Bj I* isting the sticks in opposite directions the flannel is wrung out so tight- ly that it will not drip, and then carried in the wringer
200
NUKSI.S'G
to the bed. By keeping two stupes in use, the one need not be rentovi <1 until the other is ready. The skin hav- ing been first dried] the folds of the fianm-i air shaken out: the stupe is then put on and covered with a thick layer of wool and one of oiled muslin, such a covering being always allowed to overlap the poultice or fomentation by at least two or three inches. A fomentation or stupe over the abdomen can be kept in place by means of a many-tailed bandage which should be slipped under the back before the stupe is prepared. After stopping the use of stupes a layer of cotton- wool or flannel over the part for a day or two is ad- visable. Small hot compresses for the eye, breast or neck can be wrung out tightly, and perhaps best, in a lemon-squeezer or potato-ricer. Hot compresses are applied to the throat for spasmodic closure of the glottis as in spasmodic croup. Either hot sea sponges or layers of lamb's wool or flannel may be used instead. Since it is the combined effect of heat and moisture that is desired, they should be changed every ten or fifteen minutes.
The material used for hot fomentations for the breast should be cut in circular pieces large enough to cover the breast, and should have a small round hole in the middle for the nipple; the latter should never be covered.
In cases of bronchitis, especially in children and after a tracheotomy, warm moist air often helps in allaying the inflammation, relaxing the muscular ten- sion and rendering the breathing easier. For such cases a moist air tent can readily be Improvised by con- necting by means of cords four sticks and stretching over the top a sheet, while another sheet is stretched
I
COLD APPLICATIONS
ioi
around the sides and reaches to the floor. In this way the bed is covered in entirely except for a small space which is left on the right side, sufficiently large to admit enough fresh air and to allow of the necessary care of the patient. Into this canopy the spout of the steam kettle is introduced. A certain amount of fresh air is, however, always necessary ; otherwise the procedure may he too exhausting and productive of harm rather than of good.
The action of heat differs from tliat of cold, in that heat causes expansion and dilatation, while cold con- tracts. Heat increases the bodily warmth, cold de- creases it. Cold may prevent suppurative processes, while heat tends to promote them. Both act as seda- tives to painful nerves.
In inflammation a portion of the tissues is injured and certain changes occur, which arc evidences that Nature is endeavoring to repair the injury done. These changes are associated with redness, heat, swell- ing, and pain, which in their combination arc largely the expression of an increased supply of blood to the part Unfortunately, Nature in her efforts too often goes beyond what is useful to the organism, and when the inflammation threatens to become too acute, it may be desirable to check it in its progress. It is just here that the value of cold applications is most marked. Acting as they do by contracting the small blood- vessels of the part they lessen the amount of blood directed thither, and so are often successful in pre- venting the formation of pus.
Cold i I applied either by means of the cold bath or by compresses, packs, sponging, coils, or ice. The cold bath best allows of the general application of
102
XUftSING
cold. When this is used for its stimulating effect, it should not as a rule be continued longer than from three to five minutes, and a vigorous nibbing should follow, in order to secure reaction. The cold pack and ice-water sponging arc used, as well as the cold tub, to reduce fever in the manner described in the chapter on Baths. Cold compresses are made of two or three thicknesses of lint or linen wrung out of cold water and applied over the inflamed surface being changed frequently. If iced compresses are ordered, a small block of ice partially wrapped in flannel is placed in a basin: there should be two compresses, one of which is kept on the ice, while the other is on the patient. They are thus kept constantly cold by frequent changing. A little vaseline should be rubbed on in order to prevent irritation of the skin. Compresses arc particularly useful where little weight can be borne. In swelling and pain in the knee-joint the joint is sometimes swathed in thick flannel com- presses which arc kept saturated with ice-water.
The most effectual way of applying cold continu- ously is by means of the india-rubber ice-bags. These can be made in different shapes; for instance, helmet- shaped for the head, but long and narrow for the neck and spine. Perhaps the most useful of all is the simple ice cap. The ice should be crushed into small pieces and mixed with a little common salt to intensify the cold. The bag should never be more than half filled, and one must be particular to expel the air, as far as possible, before screwing on the top. A layer of moist lint or cotton is always placed between the skin and the bag; otherwise the extreme cold is not only painful, but is apt to irritate the skin, even produc-
COLD APPLICATIONS
203
ing "frost-bites." The effect should always be care- fully watched. If possible, it is better to suspend the bag, as the weight is sometimes a source of discomfort to the patient. A bandage can be fastened to the neck of the bag, and the two ends pinned to the pillow just high enough to allow the cap to barely touch the head. At times a piece of ice is wrapped in moist lint or old linen and passed gently over the head in order to cool it. Care must always be taken to refill ice-bags before the ice has melted ; nurses are not always thoughtful enough about this, and a doctor's confidence in a nurse is justly shaken when he sees such neglect.
For certain cases iff poultices are sometimes better adapted than bags for the reason that they fit any part of the body and a greater degree of cold can be obtained They are usually made of two parts of crushed ice to one part of linseed or bran together with a small amount of salt. Two bags of oiled silk arc made of the required shape and size, one being smaller than the other ; all but one of the sides arc closed by means of adhesive plaster. The smaller bag is then filled about two-thirds full with ice, closed and slipped into the larger bag.
Ice-water coils are sold by the manufacturers but may be improvised from rubber tubing, which may be sewed upon a piece of rubber cloth in circles about an inch apart for five or six romuls a yard or two of tubing is left at each end to be used as a siphon. A large pan of ice-water is raised above the patient, into which one weighted end of the tubing is placed, with a funnel inserted into it covered with gauze to prevent clogging, while the other end is
204
NU/tsr.vc
laid in a second basin on the floor which receives the water. The method is very cumbersome, and attention is needed to see that the upper pan is kept full. Coils are sometimes ordered for the head in delirium aitd for the abdomen in tympanites. The stream of water may be regulated by a stopcock, thus making the same amount of water last longer.
The process of crushing ice necessarily takes place in a hospital every day, and for this purpose a stout canvas bag should be kept on hand, in which the ice may be placed and beaten with a mallet when a large quantity is needed. For breaking up small pieces, an icepick is best, but in doing this at night the nurse must take care not to disturb her patients. Ice may be easily and noiselessly cracked with a stout hat- pin. In private nursing, where only a small quantity is needed, it should be pri served from melting by being wrapped in flannel.
By lotions arc meant medicated moist applications ; these may be either hot or cold. In using an evaporat- ing lotion one thickness of lint or muslin is saturated and left exposed to the air to promote evaporation. The applications arc changed often enough to keep the lint moist.
When non-evaporating lotions arc ordered, lint or muslin, folded as for an ordinary cold compress. and wrung out of the required solution, is applied and covered with oiled muslin.
CHAPTER XI.
C'di nikk-Irkita.vis. — Mustahd POULTICM ami Plasters. — 1 i in :.,!.-. i —Iodine.— Cuppikg. — Canihakiues. — Th* CAunay.
Counter-irritants are therapeutic agents applied ex- ternally to produce a condition of irritation or inflam- mation, in order to relieve a diseased condition in some adjacent or deep-seated part of the body. By the ap- plication to the skin of a substance which will irritate the ends of the sensory nerves and dilate the blood- vessels of the part, the flow of blood through these vessels is increased, and the tension in those more deeply seated is lowered as a result of reflex nervous influences which arc as yet imperfectly understood. If an irritant be placed directly over an affected part, relief is often quickly obtained, and irritation set up c K at some distance from the seat of the disease is also frequently beneficial. Thus, pain in the head or abdomen may be relieved by a mustard foot-bath, since the vessels of the lower extremities, dilating, at- tract large quantities of blood to them and relieve con- gestion in those of the head and abdomen.
By the use of counter-irritants we may produce at will:
(1) Mild irritation ;
(2) Irritation producing inflammation ;
(3) Vesication or blistering.
Mild irritants arc called rubefacients, since they
ao6
KUNSING
cause redness of the skin by distending its capillaries. All classes of irritants act as rubefacients when applied only long enough to produce such an effect, but those commonly employed are mustard, turpentine, iodine, and aqua ammonia. Dry cups may also be used for the same purpose.
The mildest mustard application is the mustard poultice: it is made with linseed meal in the same way as an ordinary linseed poultice, except that i oart of mustard is well mixed with 6 parts of the meal. This may be left on as long as it retains its warmth. Its action is more gradual tod less irritating than that of the mustard plaster, which is made of mustard mixed with flour in different portions according to the effect desired. The usual formula; call for from i to 6 parts of flour or meal to i of mustard, and the nurse should be able to state the exact amount of mustard used. These ingredients are rubbed thor- oughly with cold or tepid water into a paste, which is spread between two layers of muslin or linen of the size required: the plaster is applied for from ten to twenty minutes, the outside being covered with folds of linen or cotton to absorb any superfluous moisture. The skin of one patient may be much more sensitive ind respond more quickly than that of another, and when the stinging sensation is acute and the skin wi II reddened the plaster may be removed. Care should be taken not to leave it on long enough to blis- ter the skin, as may happen with delirious or uncon- scious patients if the effect is not closely watched Where the skin is very tender, as with children, the proportion of mustard should be diminished by one- half and the plaster left on only a few minutes, just
COUNTER/K/i/TANTS
I07
long enough to produce redness, after which a warm linseed poultice should be substituted for it. After a mustard plaster has been removed, the skin is dusted with rice powder, anointed with cold cream or vaseline, riiul civ. ml with a soft piece of muslin. If the irrita- tion produced is very great a layer of cotton may be added in order to exclude the air.
Mustard leaves, or sinapisms, arc frequently or- dered, but, though far more convenient, they do not take the place of the old-fashioned mustard plaster. The effect is very rapid and they cause so much dis- comfort from the time that they are applied that they frequently have to be removed before the desired ef- fect is produced. Their chief recommendation is that they arc ready at a moment's notice, a* they need only to be dipped in tepid water and put on. A thin piece of muslin or gauze placet! between the mustard leaf and tlie skin renders its effects more gradiul. When the skin is thick and its action sluggish, the surface should be first scrubbed with hot water and soap to remove fatty substances, and then rubbed brisk- ly before applying the mustard, otherwise the result obtained will be very slight and the process will take a long time. Mustard should not be mixed with hoi water, as this destroys or lessens the strength of the volatile substance which gives the drug its irritating properties. As soon as the necessary reaction has been produced the plaster should be at once removed. The effect should be watched carefully, lest the action be more extensive than was intended and a serious blister result. Where the skin has been over-irritat- ed the white of an egg will be found very soothing.
ao8
NURStSG
This may also be incorporated with the plaster before the latter is applied.
Capsicum and belladonna plasters, as is the case with mustard leaves, come ready prepared. Iti applying them the back of the plaster is heated slightly, the face gauze is pulled off and the plaster is then fixed firmly and smoothly to the skin. To facilitate removal it should first be soaked with alcohol.
A spice plaster is made by mixing ginger and cloves (two teaspoonfuls of each) with a teaspoonful of cay- enne pepper, and a tablcspoonful of flour, enough brandy or water being used to make a paste. This is spread between two thin layers of muslin.
Turpentine is also in common use as a counter-irri- tant, but is chiefly applied in the form of stupes for abdominal pain or tympanites. These are prepared and applied much as hot-water stupes. Half an ounce of turpentine is mixed with about a pint of boiling water ; the flannel is dipped in it and wrung out very tightly. The mixing with the water tends to emulsify the turpentine (of course the oil will not dissolve in the water), and renders its application to the skin more uniform than it would be if it were sprinkled over the flannel; it also lessens the danger of causing blisters. The stupe should be applied as hot as the patient car, bear it, and should be covered snugly with cotton wool, oiled muslin and a bandage. It may he repeated in fifteen or twenty minutes if the pain or distension is not relieved, provided that the skin is not over-sensi- tive.
Another excellent method of applying a turpentine stupe is as follows: Take of olive oil seven parts, tur- pentine one part : mix well : pour on a layer of absorb
COVNTHH-IRRITANTS
100
ent cotton or thin pad of gauze and apply to the stir face of the abdomen once in six or eight hours ; over this apply the, usual hot fomentations every hour. This method obviates any blistering and can therefore be used much longer.
Tincture of iodine is applied both to the skin and mucous membranes, a camel's-hair brush or a swab be- ing used to paint the fluid lightly over the scat of the pain. This first coating is allowed to dry. and a sec- ond then applied. More than two coatings arc apt to blister, and on sensitive skins one will be found suffi- cient. To prevent blistering the application should not be repeated before the fifth day. As a rule it is best to use it early in the day after the bath as its effects need to be watched, and lew disturbance of the patient will be necessary. If the smarting is in- tense, sponging with alcohol will relieve the DSlA Iodine stains may be removed by soaking in a 2 pel cent solution of carbolic acid.
Aqua ammonia may be ordered, as its irritating qual- ities serve as a stimulant where immediate reaction is required, as in conditions of shock or unconsciousness. A piece of lint saturated in the solution is applii d u su ally between the shoulders, being closely covered with oiled silk, and left on for not nvi r five minutes, other- wise it may burn deeply. Ammonia is also used as an application after bites or stings from insects or poisonous reptiles.
Chloroform is used alone as a rubefaeit nt. It causes redness and smarting of the skin, and will blister if left on too long. It is also employed in liniments, both for its irritating and sedative qualities.
Liniments are of various kinds. Thcv mav be di\ id 14
'MUM cfcusr* — stimulating and soothing
hay are frequently used to allay muscular
iMitt, «nJ o*h be applied with friction and well rubbed
Hat tmkti in the solution and bound on
•vtliMy part lor a short time often answers the
tul irritant, producing an crup- ySdt ilk *h« fcww of tittle vesicles that may become pus- wJv^ \f) o four drops rubbed on with a piece
ol Ifctirt'. U* enough to apply to a surface of from -h wptare. The effects should be care- R»U> *-tk'bc\t and as soon as the skin is well rcd- )H*t'l the |>*tt i* rubbed with sweet oil to remove »K tfttifttttt <Mht a poultice applied. Its action is so .\«tul lh*» phvsicians frequently dilute it with an *iV*t AMKHUit of olive oil or oil of sweet almonds.
i s o kinds, wet and dry, and is some-
relieve inflammations of the eye, lung.
i'ii muscular pains. Small glasses arc
for the purpose, and come in sets of
1 * ;uc not obtainable, wine-glasses or
.«■. will answer. To prepare for dry
, mutches, and cups arc necessary.
II to take a stiff metal probe or piece
the rinl a small piece of cotton,
ij;nitr it, swab the inside of the
HU like glass. The heat causes
•o tli.it some is driven off,
mm formed is filled by the skin
|| lilrh lion is placed. The main
I hul (In edges of the cup must
I { to burn the
i >i|.fc urc applied at one time
COU\TE/t-lkA'ITAXrS
21 I
and allowed to remain on five minutes, after which they arc removed by making pressure about the glass and inserting the tip of the finger under the edge, so as to let in the air. Linseed poultices are sometimes used after the removal of the cups: in this way the dilatation of the blood-vessels may be kept up for some time. The process of wet cupping is carried out in much the same manner: one needs in addition a scarificator or small scalpel, a few sponges, and a dressing of lint for the wound. After the skin has been scrubbed with hot water and soap and washed off with a 1 :20 carbolic acid solution, the surgeon makes a few small superficial cuts, over which the cup is applied. After a sufficient quantity of blood has been withdrawn, the bleeding may be checked by sponging, a pad of lint is placed on the surface, and held in position by a covering of gauze dipped in cel- loidin or by rubber strapping.
Cantharides is used for blistering. It is employed either as a plaster or in the liquid form; for the latter the powdered cantharides is dissolved in collodion (ves- icating collodion). The plaster is the preparation most often used. The physician usually orders a plas- ter of a definite size and designates the part to which it is to be applied, but if no definite directions have been given the nurse must not use one larger than three inches square. The object of scrubbing the skin first with hot water and soap is to remove the oiljl substances or anything else that might interfere with the action of the plaster. The plaster is prevented from becoming displaced by passing a bandage around it loosely : there must be no pressure, as plenty of room must be left for the formation of the blister; and
212
NIWSIXG
tor this reason the plaster should not be held in place
by adhesive strapping, for if it cannot yield pain
will result from this tension. The plaster is left on for
It .in four to eight hours; in children from two to
fi.iu boon will l»' long enough, according to the effect
desired. When the skin ia well reddened the blister
I Mid a poultice applied. If it is necessary
U) Ml i' i. Hid vesication has not appeared at the
•nd of eight hours, a linseed poultice may be put on
\it pfa I i to su|)j)lcment its action. Great care
iltould Ik- UterdUed when blistering applications are
used ovrr the region of the kidneys, or anywhere, in
n the case of patients suffering from kidney af-
tu i intharidei i> a most violent irritant, and not
i.iii.'jiunlly causes strangury, or may even set up an
Miiitr nephritis. In applying the cantharidal collodion,
llu' »|iarr to Ik- c<ivcrcd is first outlined with oil to pre-
hr tpnwUng of the vesicant : the collodion is
li. Mirfacc by means of a camel's-hair
bnilhi imil afterward covered with a layer of soft lint
Mlk.
d/Ma a Mister, the lower part of the bleb is punc-
lll II • alpcl or tl»e scissors, and the fluid which
ftimi ii lit on absorbent cotton; when it
Is amply I lil of oxidc-of-zinc ointment
i applied and held in place with
nf strapping. One must never remove the
llll lei at the first dressing. Sometimes
II la i" have the fluid reabsorbed, in which
Hltl in taken to prevent rupture of the
U
mi ordered now-a-days, except for i wet cupping ia more cleanly
LEECHES
213
and usually answers the same purpose. A leech is capable of removing from a drachm to half an ounce of blood. The skin, after being scrublwd briskly with soap and water, is dried and rubbed, and the leech applied. This is done by placing (Ik- animal in a glass tube or medicine-glass with its pointed extremity (the head) toward the orifice of the glass, which is in- verted and applied to the spot where we wish the leech to fasten itself. If it is slow about biting, a little cream rubbed over the spot or a drop of blood from a needle-prick will cause it to take hold, h may be left on for from half and hour to an hour, according to its activity: if very sluggish, it should be gently stroked with a bit of linen. When full it generally lets go of its own accord ; if not, a little salt sprinkled on its head will cause it to drop off. An attempt to pull it away may result in the breaking off of its teeth, which when left in the flesh may set up inflammation. To increase the bleeding after the removal of the leech hot poultices or stupes are useful ; where it is too free, a compress snugly applied or ice wrapped in lint, and held in place by a bandage over the wound, will usually be sufficient. The patient must be watched until the bleeding has ceased. Leeches should not be applied over large blood vessels — bony surface*, over which pressure can be applied, should be chosen. The same leech should never be used twice. Leeches arc best kept in I jar of water covered with a perforated top and having a little mud at the bottom: it is not neces- sary to change the water often. Those of the Ameri- can species arc the best to use for children, since they abstract less blood and are less vicious than foreign leeches.
2I4
.VURSIXG
The Actual cautery. — By the application of the ac- tual cautery-, as opposed to other methods of cauteri- zation, is meant the use of the heated iron. The most valuable form of cautery and the one most often employed in hospital practice is that known as the thermo-cautery. The instrument invented by Paque- lin of Paris is perhaps the most suitable (Fig. 6). The principle of the apparatus i% l>ased on the prop- erty possessed by platinum of remaining incandescent.
Re*.
Pterin* Caittot.
when heated red-hot, as long as the vapor of some highly combustible carbon compound is thrown upon it Platinum points, of shapes varying according to the purposes for which they arc to be used, are at- tached to a tube connected with a bottle of benzine, the vapor of which is pumped slowly by means of a rubber hand-bulb into the hollow platinum point.
When not in use the different parts arc kept in a
ft
TUB CAUTERY
2I5
b03C in special compartments which allow the instru- ment to be safely carried about.
About the employment and care of the Paquchn cautery we shall now say a few words:
1. The preparation of the instrument for use: (a) A small quantity of benzine is poured upon a piece of absorbent cotton which is placed in the bottom of the bottle, only as much as is sufficient to saturate the cotton being used. This precaution prevents the es- cape of any excess of benzine when the earners in in use, for if a bottle containing benzine as an ordinary fluid be used, the liquid occasionally gets into the rubber tubing and an explosion may occur, (b) The rubber tubing with the bulb is connected by means of the stopper to the bottle containing the benzine, and the platinum tip is screwed to the handle, the other end of which is attached to another piece of tubing, (f) After firmly adjusting the handle to the platinum point selected for use, the tip should be held in 1 In- flame of a Bunscn burner or of an alcohol lamp: then the nurse should attach tlve benzine bottle by the flange on its side to her waistband, and be read y to force air through the bulb by squeezing it with the right hand. As soon as the platinum point becomes red hot, she should squeeze the bulb gently, thereby forcing the air charged with benzine vapor through the tubing to the point where it ignites and maintains the heat. The nurse is frequently called upon by the surgeon during an operation to prepare and to take charge of the cautery and keep it ready for use: to accomplish this she must squeeze the bulb gently and at regular intervals. If the pressure is too forcibly or foo quickly made, more benzine than is necessary is
ai6
NU/iSIXG
burned and the platinum point becomes red hot The tips are not often used in this condition, being gen- erally employed at black heat.
2. The therapeutic application of the cautery : As a counter-irritant it sometimes serves to dissipate effu- sions around or in joints, and is of great value in re- lieving the pain attending stiff neck and the various forms of so-called muscular rheumatism.
To produce counter-irritation with the cautery, the parts to be treated should not be actually touched, but the heated tip is passed quickly to and fro close to the surface, without, however, ever coming in contact with the skin. Such an application of the cautery is at times followed by the most gratifying results, as it will relieve pain almost anywhere, and at the same time is not accompanied by any blistering or marking of the surface of die skin.
Very frequently the actual cautery is used for con- trolling hemorrhage in abdominal surgery, where surfaces from which adhesions have been separated persistently bleed ; thus, for instance, where there is a broad area of oozing, the cautery lightly applied will often control the hemorrhage.
3. In some instances the surgeon uses the cautery in the place of a knife to divide tissues.
4. The Care of the Apparatus. — Since the cautery i> an 1 ■>.|H.-!i-.i-. i.- in-!: .iiiicni. gTHl CBH niit-t In t.iku) in returning it to its case after use. The points arc very delicate, so that the apparatus can be ruim I more easily than one would imagine. The following rules should be observed.
First; If there should lie burnt particles of tissue clinging to the platinum tip. it is held in the alcohol
THE CAVTLhV
2I7
flame until the metal is brought to a white heat so as to consume whatever is adherent to it. While the tip is still hot the handle which is attached to the rubber tubing is to be removed, so as to prevent any benzine from being carried into the tip while it is cooling.
Second: After the handle with the attached tip has been removed from the tubing, it should be so placed that the tip docs not come in contact with any surface whi<h might indent it and thus occlude the canal. When the metal has sufficiently cooled off, the handle is unscrewed, and each part immediately placed in it* proper compartment in the case.
Third : Under no circumstances is the platinum tip to be placed in water for the purpose of cooling it.
Fourth: Finally, the instrument should be carefully arranged in the several compartments in the box and the latter kept in a safe place. If the cautery is to be packed in an instrument-case, the nurse must be care- ful to place it securely in a position where it will not be jolted or in any way come in contact with hard surfaces, so that any chance of injury to it may be avoided.
CHAPTER XII. MtMcixu.— Method or Admixjstsatiox.— Dosage.— Weights
AXD MeaSUKES.— MuiCINE-CLOSETS-— MttiK'tJSK Ll*TS.
The administration of medicines is a duty that begins early in the first year of a nurse's instruction. and is associated with more or less fear on her part lest some error be committed. To be quick and ac- curate at the same time is an impossibility, when at- tempting to give medicines at first, and there i- M cause for discouragement because it takes so long to make quite sure that the quantities are correct. A be- ginner should first act as an assistant, being allowed to measure out any harmless doses ordered, until she has overcome her early awkwardness and is familiar with the different measures. It is necessary that a woman, who is a nurse or who wishes to become one, should know more or less arithmetic, at least enough to com- prehend clearly the different standards of weight and measure, and their relations to one another. Thus it is often necessary to deal with fractions of doses and to know what is meant when the strength of a solution is stated in percentages ; frequently a nurse will be required to dilute a solution of a certain percentage to another of quite different proportion* If the princi- ples on which these processes arc based be not under stood, the reckoning must be done mecli;ini>;ill. , with
its
ADMINISTRA TlOX OF MEDICINES 1 1 9
but little knowledge as to whether it is correct or not, and consequently will always he attended by a certain amount of danger. If there be any one thing that must be guarded against, it is the habit of carclcss- . ness: the nurse may have become so familiar with the dosage that an error would seem an impossibility. but it is to be remembered that a mistake is always possible. The rule made in the very beginning, and never departed from, should be this — viz. to look at the medicine-label and dose twice before giving any drug — once before it if measured out, and a second tlim just before administering it to the patient — and never to give a medicine from a bottle or box that is not properly labelled Nor should medicine ever be recorded as given, before the patient has actually taken- it. It may seem more convenient to record it a little earlier, and the intention may be perfectly good, yet this is a rule which under no circumstances should ever be disobeyed.
There arc some medicines that act simply upon the surfaces with which they first come in contact — upon the skin if externally applied, or upon the mucous membrane of the stomach or intestines if given inter- nally ; but the majority of drugs when introduced into the system arc first absorbed into the blood, and by it are carried to the tissues an. I organs upon which they act, producing certain changes in them. The acti\it\ of such drugs depends largely upon the rapidity with which they arc absorbed into the blood. There BR five paths of entrance for medicines into the circu- lation: by the digestive tract, the cellular tissue, the rectum, the skin, and the lungs. The route most fre- quently chosen is by the alimentary tract; the most
220
M/tSh\G
rapid, and the one therefore most often employed in emergencies, by the subcutaneous tissue.
Medicines given by the mouth are absorbed partly in the stomach, but to a greater extern, and In :i few cases almost entirely, in the intestinal tract. They arc given in solution or in the form of powders, pills, cap- sules or triturates. In giving solutions the bottle is first well shaken, then uncorked, and the dose pre- scribed is poured into a medicine-glass, and diluted with as small a quantity of water as the nature of the medicine will jiermit. A dose is often rendered much more disagreeable and nauseating to the patient by the addition of a large quantity of water ; sometimes, how- ever, it is desirable to have the preparation well dilut- ed as in the case of potassium iodide. If the medicine is very disagreeable, a small piece of ice held in the mouth just before taking it, will lessen the sensibility of the nerves of taste and render the flavor of the dose less noticeable; or if the medicine be mixed with crushed ice or seltzer water, the same effect may be obtained. To hold brandy, whiskey or hot water in the mouth for a few minutes, or holding the nose while the close is given, has been recommended. A little cold fresh water or seltzer to rinse the mouth .iml lake away the taste should be given immediately afterward. Oils and fluid extracts are readily taken in capsules ; this is the most pleasant way to take i oil, but if preferred it may be given in a little iheny, brandy, or strong coffee. Thus two drachms of sherry may be placed in a medicine-glass, the rim and i l> being moistened with it, and the oil then poured care- fully into the center: lastly, another drachm of sherry is poured on the top, and the whole taken in one swal-
ADMINIS TRA TIGS ()/■ MF.nfC/.SF.S 2 2 t
low. Another way is to take equal parts of the oil and glycerine ami flavor with a few drops of the oil of cinnamon or some other aromatic oil.
Another method is to first let the patient rinse his mouth with water as hot as it can be borne, then take the oil and again rinse the mouth with hot water. Some prefer rubbing the inside of the glass with lemon and adding a few drops of the juice to the oil. For children who cannot take it without vomiting the oil m.iy be emulsified by adding a little milk and sugar and shaking. Castor-oil is best given at bed-time. In giv- ing medicine to an obstinate child the nose should be held firmly enough to oblige the little patient to open his mouth in order to breathe. The nurse watches her opportunity, inserts the spoon, presses the back part of the tongue gently down with it and slowly empties it.
Pills and capsules conceal the flavor of medicines, and arc therefore much in vogue, but their action is slowi-r than that of solutions, and patientl sometimes have difficulty in swallowing them. Tasteless powders may be given mixed with a little water ; those with a disagreeable taste, such as those containing quinine, are wrapped in wafers of rice-paper or enclosed in cap- sules of gelatine. The wafers COttie in boxes ready prepared and are about two inches square. One is moistened and spread over a teaspoon ; the powder is dropped into the centre, and the wafer folded over it; the spoon is now filled with water, and the bolus hav- ing been allowed to slide will back on the tongue, a drink of water is taken. If wafers are not obtainable, a small square of thin tissue paper will answer the purpose. Gelatine and wafer-paper are dissolved rap-
Ill NURSING
idly in the stomach. Effervescing powders arc always given in from a half to two-thirds of a glass of cold water and taken during effervescence. Insoluble pow- ders, such as calomel or aoelanilid, should be placed on the tongue and washed down with a drink of water. If a patient be very ill or if it is difficult to get him to take his medicine, the admixture of a little milk or gly- cerine with it will often enable him to swallow it. In giving pills one must always be sure that they are freshly made up, as they arc apt to become hard and dry from standing, and then will not dissolve, but be carried through the alimentary tract without producing any effect. Compressed pills are free from this ob- jection and dissolve readily. In giving a pill it is placed far back on the tongue and followed quickly by a drink of water. If the patient cannot swallow it, as happens in some cases, more especially with children. the pill may be concealed in a small piece of bread or jelly, but if this method docs not answer it may be crushed up and given as a powder. Force should never be used in giving a pill to a child as there is danger of pushing it into the larynx.
It is convenient to give some medicines in the form of triturates or tablets. By trituration we mean the grind- ing and nibbing of solid substances until they arc final- ly pulverized. They are prepared by adding sugar of milk or sulphite of soda in certain proportions to the drug and triturating thoroughly. For omv< nicnce in pressing >"!. tablets th« powder b mixed into ■ paste with weak alcohol, the latter being subsequently al- lowed to evaporate.
The word "subcutaneous" (from the Latin, sub, under, and cutis, the skin) and the word "hypodermic"
_
SURCUTslXF.OUS MEDIC A HON
223
(from the Greek M, under, and ty>/u, the skin) are identical in meaning. By hypodermic or subcu- taneous medication we mean the giving of drugs by injecting them under the skin. The chief advantages of this method consist in the rapidity with which ab- sorption takes place and in the avoidance of gastric disturbance*; a drug that takes fifteen or twenty min- utes to act through the stomach will require only fife, perhaps, when given by hypodermic injection. Usu- ally only solutions of the active principles of drugs are given in this way {e. g. solutions of morphin), but other drugs, such as whiskey, brandy, or ether, arc sometimes given hypodennio.-illy when rapid stimula- tion is necessary. The injections are given with a fine syringe to which a hollow needle is attached. Three points must be kept in mind in hypodermic medication : First, we must have the needle absolutely clean ; sec- ondly, we must have a pure solution for injection ; and thirdly, the needle should penetrate only the fleshy parts of the body, avoiding blood-vessels, nerves, and bones. If one be careless about having the needle perfectly aseptic, virulent germs may be introduced and find a suitable nidus for development in the. sur- rounding tissues; and if they grow and multiply, the result may be inflammation and at times abscess- forma- tion. If the solution is not sterile, of course the same danger exists. With proper care the risk with hy- podermic injections may be reduced to a minimum. If injections are given in the line of superficial blood- vessels, the fluid may enter a vein, and the drug, being carried directly to the heart, may reach the nerve- centres in concentration in a few seconds, producing alarming symptoms. If injected over a bony promi-
224
.\'UKS/JVG
ncnce, the bone may be injured ; so one always selects the outer side of tl»e arms, thighs, or hips, or the abdo- men as the place for an injection. The solutions are generally arranged so that tin: doses vary from one to fifteen minims, the latter quantity being usually the outside limit except in the case of stimulants (whiskey, brandy, and ether), of which a syringeful is given at one time. Before giving a "hypodermic" the skin is to be cleansed with absolute alcohol, the syringe loaded with the number of minims ordered, and all the air expelled by pointing the needle upward and gently pressing the piston until a small drop appears at the point. All being now ready, a fair-sized fold of skin is pinched up between the thumb and finger of the left hand, and the needle is inserted quickly in a slanting direction into the tissues for at least half an inch ; it is then withdrawn slightly and the fluid injected slowly. The needle is quickly taken out and a clean pad is pressed lightly over the spot to prevent the fluid from escaping: very gentle nib- bing upward assists in the distribution and conse- quently in the absorption of the fluid, but if at all painful to the patient, this need not be practised. There arc various methods in vogue for preparing hypoder- mic needles for use. The three principal ones are:
First: To pass the needle through an alcohol flame just before inserting it. This method undoubted!} renders the needle sterile, but it is objectionable, be- cause it blunts it, and makes its insertion more diffi- cult, and hence more painful to the .patient.
Second : To soak the needle for a few minutes in a i :20 carbolic solution, and afterward in sterilized nor- mal salt solution or absolute alcohol to remove the
"
SUBCUTANEOUS MEDIC A TIOS
225
carbolic acid. This of course must be done before the syringe is loaded.
The third and best way is to boil the needle for a few minutes in simple water or in a 1 per cent, soda solution, taking care that after being boiled it is not touched with anything but a clean piece of sterilized gauze, with which it can be held while being attached to the syringe. If no better facilities be at hand, when required for use the needle may be put in a tablespoon- ful of water and boiled over an alcohol or gas flame.
To clean the instrument before putting it away, it is washed in water and hot water is drawn through it. If in frequent use the syringe and needle may be kept in a t :20 solution of carbolic acid.
The substance to be given must be completely dis- solved and the solution, freshly prepared, since one th.it has stood for some time is liable to be decomposed, and may have a sediment in it which will render it totally unfit for use. The principal drugs used hypodermical- ly arc now made up in the form of compressed tablets, with the help of which one is enabled to make a fresh solution at a moment's notice. A tablet should be dis- solved in a sufficient quantity of distilled or boiled water. A teaspoon is probably the most convenient thing to use, as from it every drop of the solution can be easily taken up. so that no portion of the alkaloid will be lost and no smaller dose given than is ordered.
Injections of normal sail solution have become firm- ly established as a therapeutic agent and arc now used extensively. Intravenous infusion and hypodcrmocly- sis or subcutaneous injection are the procedures usual- ly employed, the latter being the more common. In a general hospital a supply of sterile normal salt solu-
NUKSIXG
tk«u should always l>e ready. The apparatus consists v<t a graduated jar with a glass nipple projecting from the side near the bottom. To this is affixed about six- rile rubber tubing, which in turn is attached to a moderate-sized aspirating needle. These should ) s be sterile and ready for use. The most common places cliosen are the loose tissues beneath the breasts, the abdomen, or the buttocks. To save the patient unnecessary pain a one per cent, solution of cocaine in.iv fat employed. The salt solution having been al- lowed to flow through the tube and needle until all the air has been expelled, the needle is inserted and usually .1 p| in place by straps of adhesive plaster. The solu- tion is allowed to flow in by gravity, the flask beir elevated only about 4 or 6 feet. The strictest aseptic precautions are imperative. The skin of the patient and the hands of the nurse must be prepared as for a surgical operation. From 500 to 1000 cc. arc usu- ally given at one time. Tlie temperature may range 1160 to 118° F., a thermometer being kept in the jar and the latter being swathed in flannel to pre- serve the proper degree of warmth.
For intravenous infusions similar preparations are made. The temperature of the solution should be IOI0 F. A bandage having been firmly put on the arm on the side remote from the heart, a vein is laid bare and incised. Instead of the needle a small glass canula is used. The solution having been allowed to flow through the tube and canula until all the air has been expelled, the canula is inserted into the vein and securely ligatcd to it. The tube is clamped with mod- erate tightness so th;it the solution runs in very slowly.
Medicines arc given by rectum only when it is de-
SfPrOSfTOR/RS
12-J
sired to obtain local effects or where the stomach can- not retain anything or must have its work lessened. The mucous membrane of the large intestine does not absorb quickly, and as a rule requires twice as long to do so as the stomach. For a stimulating effect medi- cines should therefore be given in solution, and in- jected as high up as possible in the manner described in the chapter on Encmata.
Suppositories are solid conical* preparations, made generally of cacao butter, with which the drug is in- corporated. They are firm and should not melt at the temperature of the air. but when introduced into the rectum or vagina will gradually dissolve. They arc usually ordered for their local effect, the most com- mon perhaps being those containing some preparation of opium, which is much used in this way as a local Mdatlve. The suppository is first oiled and then slipped in without force: the patient should lie on the left side, and care must be taken that it be made to pass beyond the internal sphincter muscle ; the anus may be pressed with a towel until any desire to expel the suppository has passed away.
The practice of introducing medicines into the sys- tem by inunction i> relatively rare. But in some con- ditions the rubbing in of various substances is some- times ordered ; in syphilis mercurial inunctions arc often indispensable. Tin ointment i* to be well rubbed in. The areas generally utilized arc the axillary spaces, the inner surfaces of the thighs, the chest and abdo- men. Again, in conditions of emaciation such as arc seen in tuberculosis and inanition from other causes, cod-liver oil nttd in this way is frequently of
228
A'UJt.S/A'G
value. Before an inunction is given the circulation of the skin is rendered active by a warm bath.
To obtain absorption through the lungs it is neces- sary to finely subdivide the BKdfCMKnt by means of atomizers or insufflators, and give it by inhalation. Although the spray from an atomizer is most com- monly used, the inhalation of vapor is also a favorite method. The drug should be mixed in hot water in a small steam kettle that can be kept over a lighted gas or alcohol lamp with a flame just large enough to al- low a small stream of steam to pass constantly through the spout, over which the mouth is held at a comfort- able distance. Or the drug may be mixed with a quan- tity of boiling water sufficient to about half fill a quart bottle, which is wrapped in cotton-wool to preserve the heat, and the vapor breathed in. Volatile drugs like ammonia or eucalyptus, chloroform and ether are poured on a sponge or cloth, and held near the nostril? or placed in a respirator which covers the mouth. If an irritating substance is used, with unconscious pa- tients great care is required to sec that it is not held near enough to do any injury. Nitrite of amyl is best inhaled from a small piece of fine linen or hand- kerchief.
For the local application of powdered substances the regular rubber insufflator is used; or the powder may be put into a glass tube or quill placed well back in the throat and gently blown in or else drawn in by the patient, [iquids are applied by means of the gargle, spray, sw?b or syringe. Of these the spray is most often employed, as the solution is converted into a fine cloud of spray which reaches every affected part. For removing an accumulation of mucus in the throat
dosage
229
the swab is preferable. This is made by twisting ab- sorbent cotton on a long probe or applicator. It is then dipped in the solution and applied to the throat with a circular movement of the wrist
It is necessary for a nurse to understand the effects of the drugs in common use and to recognize the or- dinary indications for their discontinuance. She should also be familiar with the maximum and minimum doses of drugs, and the symptoms following an over- dose, remembering always that variations from the rule exist for individual cases and according to special circumstances. Thus the nature of the disease, the age of the patient, his temperament and habits, the time of administration — all influence the action of remedies. Children require much smaller doses than adults, and the old have less resisting powers than the middle-aged for depressing drugs. The most gen- erally accepted rule by which to calculate the doses for children under twelve years of age is as follows: Make a fraction, the numerator of which is represented by the age of the child in figures, the denominator by figures representing the age of the child with twelve added. This will represent the part of the adult dose which is required. Thus, for instance, for a child *ix
6 6 1
years old we have = — = — of the adult dose.
6+12 18 $
Roughly speaking, we may say that between the ages of twelve and twenty-one the dose is one-half of the full dose. Exceptions to the above rule are made in the case of purgatives like calomel or castor oil; of these half an adult dose may be given to children. With opium, however, a smaller dose than the rule
230
AUA'S/XG
calls for should be given at first, since children are very susceptible to tins drug, while On the other hand, they are very tolerant of belladonna.
As physicians cannot always speak of the details of the action of medicines to each nurse, it is necessary in giving drugs to bear in mind some of the results which may follow their use. Thus a drug may not act in the same way with every one. Some people have an idio- syncrasy in regard to a particular medicine, by which we mean that it affects them in some peculiar wa\ ili .it would nut ordinarily be expected. This is particularly true of individuals with highly nervous temperaments ; and, since such an effect cannot always be foretold, nurses should be very careful to note the symptoms following the first dose of a medicine. Where an idio- syncrasy exists, the susceptibility to the drug will prob- ably be increased, and peculiar symptoms may mani- fest themselves with the first dose, which should be re- ported to the physician. In such cases the dose should not be repeated without further instructions. Again, certain medicines, if given regularly for some length of time, gradually accumulation the system until final- irked symptoms of poisoning appear. With such powerful drugs as strychnine this accumulal'nc effect be watched for. On the other hand, there are other medicines to which, when given for some time, the system becomes accustomed, so that the dose may have to be increased to obtain the desired result. When this toleration becomes established, the increase in the dose may go on until the habit of taking the drug is '/ill, and the patient thinks he cannot do without it. as is so frequently seen with opium and its alkaloid morphin. Whenever unusual symptoms of any kind
fXiSACE
23 1
have become at all evident as the result of treatment, the nurse must be particular to keep the physician in- formed, as often only through her can such occurrences be detected, and she should understand the symptoms which may follow the use of the various drugs. Frequently, where a habit is becoming apparent, a placebo is resorted to in order to quiet the mind of the patient, but the custom is to be deprecated from a moral standpoint, and no nurse should resort to hypodermics of water or salt solution or any of the various substitutes without direct orders from the phy-irian.
The time to give medicines must be carefully con- sidered. Absorption is of course more rapid when the stomach is empty, and if a prompt action i a time is selected when the stomach is not filled with food : for this reason purgatives, which act quickly, are usually ordered in the morning an hour before break- fast more slowly acting cathartics are taken at night: irritating or acid substances should be given when there is food in the stomach, and certain other drugs only at a time when the process of digestion is most active, Alkaline tonics may be given before meals; narcotics should be given the last thing after the patient has been prepared for the night, and nothing should be done to rouse or disturb him after the drug has been taken.
Some forms of food and medicine do not combine well — that is, they are incompatible; thus, for instance, if milk and acids are Riven together, the milk is apt to be rejected or to cause pain. Some drugs arc also either physiologically or chemically incompatible with
NURSING
others; thus corrosive sublimate is incompatible with all albuminous bodies, and should be given alone.
Medicines ordered before food should be given from twenty minutes to half an hour before the meal-time ; those ordered after meals should be given either im- mediately after eating or fifteen minutes later. Medi- cines ordered for a certain hour should be given promptly at that hour: three o'clock does not mean five or ten minutes before or half-past three; and it is not the privilege of the nurse to administer a medi- cine before or after the hour marked on the schedule. Unless special orders arc given, it is generally under- stood that a patient is not to be awakened for medicine at night. One should not attempt to give an un- conscious patient medicine by the mouth, for it may enter the lar> nx and cause suffocation, or an aspiration, pneumonia.
In hospitals, accurate lists should be written out by the head nurse with the names of patients, medicines, doses, and hours conveniently arranged, and one nurse should be set apart and held responsible for their prompt and correct administration. A nurse under no circumstances should take upon herself the responsi- bility of suggesting or prescribing a medicine. If con- sulted as to what it would be best to give, she should al- ways refer the consultant to the physician in charge.
Medicines for hospital use should be ordered only in small quantities — not enough to last three or six months — since it is always best to have them fresh. They are liable to evaporate, and the solutions may become more concentrated when allowed to stand on the shelves, and, as supplies can be ordered daily, there is no necessity for having too much of anything on
THE MEOICIS I: c r.oXE T
m
hand. The medicine-closet is not to he converted into a small drug-shop ; unused drugs must not be allowed to accumulate in it, but should be returned to tin- hospi- tal pharmacy, as they may possibly be used in another ward, and thus expense be saved.
The medicinc-closct for hospital use is usually made with glass doors, and should In- kept scrupulously neat. If heavy glass shelves cannot be had for the bottles, it is easy to cover the wooden shelves with sheets of ordinary glass cut to fit; these will prevent stains on the wood, and the closet with but little trouble can be made to present a neat appearance. The size of the bottles should vary according to the drugs which they contain. All extracts, active principles, and pow- erful drugs should be kept in very small quantities in l>ottlcs holding no more than two ounces, and each should be supplied with two labels, on one of which the name of the drug and the strength of the prepa- ration is clearly shown, another, a bright red one, being marked "Poison." Tin same precaution should lie used with external applications, and the bottle should be of glass oi some striking color and have a rough surface, so that the moment the fingers touch it it will be recognized as one containing a poisonous substance. If the medicines be always poured out on the side remote from the label, the latter will not l>e disfigured and will not be so liable to be nibbed off. Where many medicines are given, a small damp cloth should be kept to wipe the bottle before it is returned to the shelf; of course all bottles must be carefully corked to prevent evaporation. A small tray, a pitcher of fresh cold water, a glass rod for stirring, glass tubes for mixtures which would injure the teeth, a dropper, and
*34
NURSfNC
plenty of graduated medicine-glasses ought to be kept near the medicine-closet. No one but a nurse thottld perform the duty of giving out medicines in a free ward, and a drinking-glass after having been used by one patient should be carefully washed before being given to another. After use the medicine-glasses are washed thoroughly with hot water and soap, those that have been employed for oils or emulsions being washed separately: the nurse should never entrust this work to a convalescent patient. Small medicine towels made of old linen napkins or table-cloths are necessary. The medicine-closet should always be kept locked, and on no consideration should a patient (no matter who he be) have access to it.
A nurse should practise the reading of prescriptions anrl understand their component parts. As a rule a prescription is made up of four parts (i) the super- scription—the letter R, an abbreviation for Recipe, the imperative mood of the verb Recipio: (2) the inscrip- tion— the names and doses of the drugs prescribed: (3) the subscription — directions to the dispenser: (4) the signature; instructions to be written in English for the patient. In a typical prescription the ingredi- ents are, the basis or active ingredient ; the auxiliary ; the corrective; and the vehicle.
AIWREVIATION'S
ns
Abbreviations.
on, ana («»<«) of each.
Abitr., Abstraelum, abstract.
Ad, up to, to amount to (the full phrase being quantum sufheit ad).
Adde, add.
Ad lib., ad libitum, a* much as desired.
All. hot., alicntis horis, every second hour.
All. noc, alterna nocte, every other night.
At]., aqua, water.
Aii. desl., aqua dcstillata, dis- tilled water.
Aq. pur., aqua pura, pure wa- ter,
Bit. nid.. bis in dies, twice daily.
C-, Cong., congius, a gallon.
e., cum, with.
c.c, cubic centimeter (com- monly written rr.).
Cap., capiat, Let him take.
cm., centimeter.
Comp., compositum, com- pound.
Conf., confectio, a confection.
Conlin , continuatur, Let H be continued.
Dccub., decubitus, the lying- down position.
Del, dctur. Ixrt it be given
Dil , dilutus, dilute.
Dim., dimidius, one half
Dn>„ divide, divide.
Div. in p. <tq, dividatur in par- tes scqualcs, Let it be di- vided into equal part*.
Drachm., drachma, a drachm.
Emp., emplastrum, a plaster.
Enem., enema, injection.
/•"., Fahrenheit.
/•".. fac, make.
Fl. Fid., fluidus, fluid.
it., fiat or nant, Let there bt made.
Garg., gargarisma, a gargle.
Or,, granum or grana. a grain or grains.
Gil., gutta or gutta:, a drop or drops.
Guttat., guttatim, drop by drop.
In/ . infusio. an infusion.
Inject. , injectio, an injection.
Lb., libra, a pound.
f.l'i/., Ill|!1i T
Lot., lotio, a lotion.
.If., ulace, mix.
Mist., ti) i vt ur;i, a mixture.
.V., node, m night.
No., numcro, in number.
O., octarius, a pint
01., oleum, oil.
01 res., oleorcsina, oleorcsin.
01. olio., oleum olivx, olive ofl.
Of., ovum, .in egg.
I'ii, pilula, a pill.
P. r. «., pro re nata, as occa- sion arises.
Puh„ pulvui, a powder.
<l /., quantum raffldt, as much U is sufficient.
236
A'tWAVAY?
R., recipe, take.
Rad., radix, root.
i' or Sir., signa, write — i. *. Give the following direc- tions.
Stm.. semen, seed.
Sp. gr., specific gravity.
Sfi. or Stir., spiritus, spirit,
St., scmissi*. a half.
S. V, R.. spiritus vini rectifi- caius, alcohol.
S. V. C, vpiritus vini gallici, brandy.
S. F., spiritus frumcnli, whis- key.
Syr., syrupus. lyrup.
T. i d„ ler in die, three time* a dry.
7>., Tinct, tinctura, tincture.
Track* trochisci, lozenge*
Ung., ungucntum, ointment.
M, iniiiiiiHim, minim, the ooth part of a drachm by meas- ure
3,drachma. a drachm
J, uncia, an ounce.
3, scrupulum, a scruple,= ao grains.
Apothecaries' Weight.
20 grains = I scruple. 6o " = 3 scruples = i drachm. 480 " = 24 scruples = 8 drachms = 1 ounce.
Apothecaries' Measure. 60 minims — 1 fluidrachm.
8 fluidrachms = I ounce.
16 ounces = 1 pint.
2 pints = I quart.
8 pints or 4 quarts = 1 gallon.
Approximate Measi
A common tcaspooniul of distilled water contains about
|
60 minims |
= i fluidrachm |
m Fl. J). |
|
1 dessertspoonful |
■ 2 fluidrachms |
bFI. Blj. |
|
■2 tablespoonfuls |
= 1 llnidounce |
= FI. jss. |
|
l wine-gljt<4fnl |
= 1 S tluidouncc* |
= PI. J1SS. |
|
1 teacupful |
= 4 ounces |
«= Oj. oj. |
|
1 pint |
= 16 ounces |
abbrevia tions
Abbreviations of Time for Giving Medicines.
A. C. (Ante cibum) before meals.
P. C. (Post cibnm) after meals.
A M. (Ante meridiem) in the morning, before noon.
P. M. (Post meridiem) in the evening.
q. I. h. (quaque hora) every hour.
q. 2 h. (secunda quaque hora) every two hours.
q. 3 h. (tenia quaque hora) every three hours.
q. 4 h. (quarta quaque hora) every four hours.
237
CHAPTER XIII.
Drrr in Disease.
.
The importance of diet and its relation to the need* of the system, whether in health or disease, can hardly be overrated, and to properly appreciate this re- lation one must have at least a general idea of the con- stituents of the different varieties of food. The doctor orders what food a patient shall have, hut the nurse has much to do with its preparation and administration. It is unfortunate that so few nurses understand any- thing about food-composition and the principles under- lying food-preparation, since for invalids these are of paramount importance. In hospitals it not infrequent- ly obtain.- in the nurse's mind thai If BO] Ott pari of her duties may be neglected, it is the attention given at meal-time. It is pretty well understood among nurses ilia i medicines are to be given promptly at the time they are ordered, and any neglect of this duty is con- sidered a grave misdemeanor ; but it has not yet be- come clear to all women who nurse in hospitals that it is equally important that the patient's food should hr. given at stated intervals, in correct proportions, and in an inviting form. Fresh air, pleasant surroundings, ami food [".mil all have i 'listuld therapeutic value an' will do much toward restoring health or improving a patient's condition; and with these a nurse has much to do. In the free wards of hospitals it is not all uncommon thing to leave the distribution of the food
IN
biBt
m
to the ward maid, with but a very hasty or superficial supervision on the part of the nurse: the result is that an overloaded plate of food of various kinds may be carried to a patient who has not the appe- tite or inclination even for the daintiest morsel ; the plate is put down and left during the time prescribed for the meal, and then carried off again by the maid j and it may only be quite by accident that the nurse learns afterward that the patient has eaten nothing. Moreover, such want of thought means not only neg- lect of the patients but also a wanton waste of good food.
Nor can it be expected that women coming into
'.:••■ ; J i! . new tu the w ■( ]■: and tO BD» "•'•. should ;:hv:i\ |
realize the importance of this part of their duties unless the fact has been thoroughly impressed upon them. Skill and intelligence in this, as in the other depart ments of nursing, require that theory and practice should go hand in hand: theory alone will not do, nor will it answer to depend upon chance opportunities to put theoretical teaching into practice. Lectures and demonstrations are better than nothing, but being talk- ed to and seeing the demonstrations of some other person will help the nurse but very little toward per- iag the work skilfully herself, nor will the prin- ciples upon which they are ha-.rd appeal to her so forcibly as when she can actually see certain results follow in her own experience. But, if she once under- stands the principles, her attention to the nourishment of the patients under her care is less likely to be a mere perfunctory duty, ami, knowing the results which she wishes to obtain, she will be interested in watching for the success of her efforts. Fortunately, the increased
XURS/S'G
£tvca to domestic science in its various
tt*HKbv« roakv- i: MOW possible for training-schools to
»\yv competent instructors in cookery for invalids.
in ;•• ■>'■ ■•'.-'wv-'. in the number of nch instructon
in hospital diet kitchens, since the first
vdtlii || hook appeared, is in itself a pleasing
UtiHMiivit that the subject is receiving more and more
tvUMvWration. Cooking is a fine art that requires to be
■uly in theory, but also in practice. In-
iii hi fliiii branch should be given in the hospital
iiincnt. which should he a model of its kind
'4V« «» its head a nurse who has been especially
,, ,nu I in ur tclencc "t" nutrition After nV pupil
Ungues familiarized with the general kitchen and ||| word with fund in quantities and its distribution, >.>it ktwuild he detailed for a course of study of foods
lln principles nun vnifil in their prc])aration, ii il part nf which should consist in the mak- ing and QOOtdng of the various dishes suitable for an
I . dietary. This course should be conducted by
a npi-ria! teacher in a well appointed smaller kitchen,
in h should be an adjunct of the larger general one.
tudy calls for a knowledge of elementary chem- miry as far as it applies to the effects of heat, cold, air and water on food, the classification and com- p ii. i ,.f the principal food-substances, and the pro- cm n;; and preparing such foods in simple
bll formi for invalids. Of the preparations ii 1 1' •hmilil he a good number to choose from, and
■I'll should go over the tests and actually pre- pare Mch dish at lca»t three times.
Ii* should assist the teacher in making it. and
DIET
24 1
be taught the principles to be observed in |»rc|>;itin^ such a dish ;
2. She should prepare it under the observation and criticism of the teacher ;
3. She should prepare it, as a test of her ability, quite alone.
As the primary idea is to instruct, the time allowed for such a course should be devoted exclusively bo teaching, and since the preparation of large quantities would take too long, and thus hinder systematic in- ftraction, it cannot be expected that all the delicacies for daily use in the hospital can be prepared in the cookmg-school. Most of the beef-tea, however, and of the broths needed for the hospital may be made daily, and in addition the dishes prepared during the instruction of the day may be contributed as extra deli- cacies to the wards. The time required for such a course is at least one month, but a better proportion is six weeks ; the class may consist of a regular section of the students taking the preliminary course. A course of this kind gives a nurse an intelligent com- prehension of the value of certain kinds of food in disease, and of the best and most wholesome methods of preparing them, so that she will afterward be able to explain to others how the work should be done when she has not time to do it herself. She will have at her command a varied and extensive list to select from, and will be taught the correct manner of serving. If she becomes a district nurse, die will be able to advise the housekeepers or mothers how they may spend small sums of money for food in the most profit- able way, and to give valuable instructions how to pre- pare it. M
*4*
NVttsrNG
i preparation for the position of head nurse in a hospital, Mich instruction gives her a practical regard i .i economy, and teaches something about household arrangements— qualities very desirable in a woman who is responsible for the careful ordering of a ward. In the ward a nurse should be detailed in turn for a- certain length of time to have charge of the nourish- ment of the patients: in this way she will know just what each one is getting, and, after serving each pa- in m's food herself, she should then go round to all the bed-patients, encouraging some to cat, finding out their likes .111,1 dislikes, feeding the helpless ones, and then making an accurate report to the head nurse of those who have no appetite and do not eat well.
The cleanliness of the refrigerator where the butter, milk, and extra food for the patients are kept should be under the supervision of the nurse in charge of the meals ; the work must be done thoroughly to ensure keeping things sweet and free from fermentative bac- teria. The milk-jugs and cans require a careful daily washing, after which they arc to be left standing full of boiling water for an hour. The greater the pains taken to instruct the nurse as to the reasons why such i.'iiiimious and strict attention to these details is nec- essary, the greater the responsibility on her part to see that the proper conditions arc maintained.
All dishes used for diphtheria patients or, in fact, for those with any infectious disease, should be kept apart from others, and not put into common use again until they have been boiled in a 2 per cent, solution of carbonate of soda for one hour. The use of the steam dish-washers — now commonly employed in large
DIET
243
hospitals — is to be commended, since in this way all the dishes can be sterilized after each meal.
Sometimes, when a patient is not inclined to eat, a little judicious management on the part of the nurse will result in a fairly good meal being taken : IOC may do this by assisting the patient to take food, encourag- ing him to try a little more, or by diverting his mind with conversation that will be of interest, and keeping his attention off what he is doing, so that ■ OH limes he will unconsciously cat a great deal more than if left to himself. Con.viKr.ilik' skill is required in idminicter ing food to helpless patients. If it has to be with an ordinary cup or glass, the vessel should never be more than half full, ami the I >uld be slightly
raised and supported firmly; care should be taken atA to throw the head so far forward as to make swallow- ing difficult. A napkin is to be folded under the chin and the fluid given gradually; an occasional stop should be made, so that the patient may not have to swallow during inspiration. If feeding-cups are used, glass ones arc preferable, as the amount given at one time can be more easily measured. For patients who must lie flat on their backs, a favorite way to give fluids is through a glass tube: an ordinary pipette may be bent at any angle desired by heating it in an alcohol flame, and through it the patient may suck his nour- ishment without having to be raised. The fluid may be taken in this way as slowly or as rapidly as he wishes, and there is no danger of any running down the outside of the cup on to the clothing ; if a glass tube cannot be procured, a small piece of clean rub- ber tubing will answer, but it ■hooM l»- milted thor- oughly after use and kept in a fresh solution of boric
244
.V6'A\S/.W
acid. Where the favorable termination of a disease depends upon keeping up tin patient's general strength, important to give nourishment as regularly at night as during the day. unless orders arc given not to waken him. Frequently ;i patient will become just conscious enough to take what is held to his lips, and at once drop off to sleep again. Patients arc apt to lie awake toward morning, when a cup of hot milk, cocoa, or broth should be ready, as this often sends them to sleep again for two or three hours. It is a good prac- tice to give a glass of milk or some light form of nour- ishment the last thing before a patient is settled down for the night.
Food given to patients in small quantities and at short and regular intervals will digest better than when the same daily quantity is taken in heartier meals at longer intervals, as the function of the digestive organs is weakened, and sympathizes, so to speak, with the condition of the general system. Food of any kind should never he left in a sick-room after a patient has finished with it, nor should it be allowed to remain on the bedside ItftOd in the hope that a little may be taken later. This applies to milk particularly, which is so much used, for it perhaps more readily than any other kind of food absorbs impurities from the air. The drinking-water is not infrequently a source of disease, and intestinal irritation has often been traced to this source, although the water itself may be apparently clear and may look perfectly pure. Where intestinal disturbances cannot be traced to any direct cause, one suspected agent may be excluded by boiling all water used for drinking purposes, and keeping it in clean vessels. The same dangers arise
DIET
245
from the uee of impure ice. Where there arc epi- demics of fevers, intestinal diseases, or cholera, drink- ing-water should never be taken unless it has pre- viously been boiled.
In private nursing the nurse usually has to make arrangements for keeping small quantities of food or milk for night use near at hand and fresh. Where a small refrigerator is not obtainable, a large dish-pan is a good substitute: the ice may be kept for a long time if wrapped in a piece of flannel and not allowed to come in contact with the water that drips from it. This can be arranged by turning a smaller basin upside down in the pan and putting the ice on it; then the milk, fruit, etc., may be arranged about it, the whole being covered over with a fresh napkin and kept in a cool place*
Food-constituents may be grouped as albuminoids or protcids, fats, carbohydrates, inorganic constituents, and water. A diet to be perfect must contain all thttt in certain definite proportions. The diet in illness will depend largely upon the nature of the disease, the amount of waste of the tissues, and the forms of food best suited to repair as much of the waste as possible.
The patient's strength is to be kept up, so that he may utilize food to the greatest extent possible to repair or prevent tissue-waste; no food should be given that cannot be readily assimilated.
In diseases accompanied by fever, wasting of the al- buminous tissues takes place, and as a consequence muscular weakness results. At the same time there is a disturbance of the processes by which food-substances arc digested and absorbed. Albumin is often found in the urine, and the amount of water in die body is
246
XUHSLVO
diminished In the weakened state of the powers of digestion which accompanies fevers, the food which: contains those substances which are most readily as- similated, and leave a minimum amount of residue, is desirable, and should be given in liquid form.
Milk is considered the perfect food in these cases, as it contains albumin, fat, sugar, and water, besides inorganic salts of lime and potash. If it disagree with the patient, and curds appear in the stools or vomiting ensue, it may be given boiled, or may be diluted with plain or effervescent water in the proportion of 3 parts of milk to 1 of water, and given in small quantities and more frequently. If it still disagree, it may be diluted one-half with barley-water, or lime-water; or bicarbonate of soda (10 grains to the pint) may be il to it. Where these fail, peptonized' milk may be given. When milk is the exclusive diet, of course the amount must vary somewhat for each individual patient, but usually from 3 to 5 pint* are ordered for the twenty-four hours; this should be divided up into equal portions, of which one is given every two or three hours. Occasionally milk cannot be taken at all, and where there is much depression the albumen of e^K in increasing quantities may be ordered.
After a course of nutrient enemata a teaspoon ful of albumen water every half hour is a safe way of return- ing to feeding by mouth. Albumen water is a simple form of nourishment when others fail; in persistent vomiting it is retained in small quantities when < vrrv- thing else is rejected; in typhoid fever, in diarrhoeas of children and when incorporated in nutritive enemata h causes less discomfort and irritation than Other forms of food. To prepare it the white only of the
DIET
247
egg is taken and well beaten anil Strained It can be i;i\ i m in orange juice or with about equal parts of cold water, a small quantity of salt being added and if desired a few drops of lemon juice and a little sugar.
Other substitutes for milk are kumyss, whey, butter- milk, or meat broths, soups, and meat extracts; these do not contain the same amount of nutriment as milk. Unless the process of preserving tin albuminoids in the broth is understood and carried out, it is of little value as a food. The broths commonly in use in hos- pitals serve more as a warm, slightly stimulating drink than as a form of nourishment ; the extracts are more stimulating, but arc only nourishing to a small extent. Meat-jellies may also be used for- administering al- buminous foods in an easily-digested form. Farina- ceous foods arc rarely ordered in fevers, as they readily ferment, and no starchy food is suitable in typhoid fever where the lesions arc in the small intestines, since the stomach, upon which we have mainly to rely in this disea- i i digest starch.
The importance of giving plenty of water in febrile diseases is now generally insisted upon by medical au- thorities. The functions of water in the body are various. It is a necessary aid to digestion, as food must be dissolved before it is absorbed, and plenty of water in the circulation helps to carry nutritive material throughout the body. It also conveys the waste products of combustion that must of necessity- be carried off in solution. In a condition of fever these waste products arc greatly increased while there is a distinct loss of water to the system through the discontinuation nf the regular food which ordinarily I contain about a third of the normal daily amount
248
\U*S/X(7
of water taken into the body. Hence it is clearly neces- sary to give plenty of water to make up the normal quantity and in addition a great deal more is needed to help to perform the extra work imposed upon the system in febrile conditions. If a patient does not ask for it. it .should be offered to him, and he should be induced to take it frequently : some advocate giving it as often as every hour during the day if it docs not interfere with digestion. In typhoid fever the nurse is now told to induce the patient to drink as much water as possible. A fresh supply is kept constantly by the' patient's bed and he is encouraged to take some every fifteen minutes. Cold water when taken at frequent intervals, will lower the tempera- ture somewhat, flush out the kidneys, and assist in carrying off waste products from the alimentary canal. It may be alternated with effervescing waters, lemon- ade, rice-water or barley-water. A little fresh cold water or Seltzer should always be given after milk or food. It removes the particles that cling about the teeth and fauces, and does away with the continuous and disagreeable flavor of food.
Tea and coffee are sometimes ordered in fever as slight stimulants. Some form of alcohol is ordered v Inn it is necessary to assist in checking tissue-waste; When the pulse becomes dicrotic, rapid, and irregular, the tongue dry and parched, and the nervous symptoms arc marked, alcohol may be the only thing which will bring the patient through.
A convalescent fever patient is allowed to return to solid food by degrees, beginning with so-called light diet, under which head are included baked custards, jellies, soft-boiled eggs, and milk-toast: then extra
DIET
*49
diet is allowed, when fowl, chops, baked potatoes, etc., may be cautiously given. The above course of diet is that usually prescribed in typhoid fever. In some forms of febrile disease, as pneumonia and tuber- culosis, where no part of the alimentary tract is in- volved, the "light" form of solid diet may be given even when there is pyrexia; in tuberculosis, in fact, any food that is nourishing and easily digested is n.Miallv allowed, being supplemented by forced feeding with fresh eggs and milk.
In diseases where fever is not a prominent symptom, and where the effects of certain foods upon the disease must be taken into account, special forms of diet are prescribed.
In acute gastritis the giving of food by the mouth may be stopped entirely, so that complete rest is af- forded to the stomach, while the nourishment is ad- ministered by means of nutritive enemata. In the milder forms peptonized milk is often ordered or egg- albumen diluted with water, antl the way is paved to solid food by the use of scraped raw beef in small quantities. Fats, starches, highly-seasoned foods, and stimulants arc to be avoided, and are not to be given except by the physician's orders.
In dyspepsia easily assimilated foods are ordered in small amounts and at fixed intervals; hence the importance of giving them promptly and in the precise quantities directed.
In chronic gastric catarrh begin with milk in small quantities and gradually increase in amount ; this may be followed later by freshly pulverized raw meat or meat extract, preferably a clear consommi to which an egg may be added. All fats, spices, an excess of
250
XUHSfXG
starchy or saccharine food and stimulating drinks should be avoided. Many patients will improve under these circumstances, but it is often necessary to adhere to a strict diet for life.
In cases of gastric ulcer there is a localized gastric catarrh and the coats of the stomach are unfitted for digestion. Give the mildest and most unirritating food. A bland but nutritious diet should be main- tained for months after all symptoms have disappeared.
In gastric cancer there is not so much disturbance of the digestive powers when the growth affects the larger curvature of the stomach, as when the pylorus is implicated. In the latter case if much food is taken it will accumulate in the stomach, ferment, and pro- duce distention. Washing out the stomach is an im- portant adjunct to the dietetic treatment in such cases. In diarrhoea caused by improper food or food in too large quantities, the diet must be restricted. Milk well boiled is the best food until the condition improves, when pulverized meal or meat infusion may be tried. Absolute rest in bed is very necessary.
In diseases of the kidney a diet consisting of milk and vegetables, together with plenty of water, is gener- ally prescribed.
In diabetes or glycosuria sugar appears in the urine. and there arc great emaciation and loss of strength. In transitory cases caused by an excessive use of sweets, a proper regulation of the diet will soon bring about a disappearance of the symptoms. Glycosuria is not un- common in gouty individuals.
In true diabetes all foods or liquids which contain sugar or anything that can lie converted into sugar, as starch and allied substances, arc reduced to a rnin-
ARTIFICIAL FEEDING
a5i
itimrn. Gluten bread is ordered instead of white bread, as, if properly made, it contains a minimum of starch.
Saccharine has the taste of sugar, with 300 times its sweetening power, but not its injurious effects. Po- tatoes, when eaten at all, should be baked. If light wines are not available, diluted spirits in small quan- tities are allowed, for the reason that they assist in the digestion of fats.
Unless a convalescent expresses a preference he should not be consulted as to what food is to be served, nor should it be mentioned until it is actually before him. All nourishment should be given punctually and at the right temperature; nothing should be forgotten. Too large a quantity should never be served. The tray and everything on it should look clean, dainty and at- tractive. Attention to all such details will assist ma- terially in putting the patient in a proper frame of mind for food. No food should ever be cooked in a patient's room and anything left over should be re- moved at once.
Artificial feeding includes the giving of nourishment by the rectum by means of nutritive enemata. de- scribed in the chapter on enemata. gavage — the giving of food through a tube passed through the mouth or nostril to the stomach — feeding by subcutaneous or intravenous injections and through a gastric fistula.
In the case of children, where only a very small amount of fluid nourishment is needed, or when adult patients keep the teeth tightly clenched, a medicine dropper can I" employed with advantage.
The nasal tabe is usually indicated in unconscious or insane patients, in diphtheria when excoriations of the mouth exist, and in cases of tetanus.
251
HOUSING
It is often difficult to induce children with sore throats to swallow food, and if tact and perseverance i':ii! to bring sboal the desired results the nasal tube must be resorted to. Older patients can be made to hold pieces of tee far back in the throat until a condi- tion of numbness from the cold is produced, after which liquid food can be taken with little or no pain. Cocaine is sometimes ordered to be painted on the fauces before nourishment is given.
It need hardly be added that we have always to take into consideration the exigencies of the particular case with which we arc dealing, and. while following gen- eral principles, be prepared for such modifications in details as may be indicated. The patient's physical comfort should be looked after; before food is given the mouth should be washed out. the face and hands bathed, the bed cover and pillows arranged ; the pa- tient should be propped up, with his shoulders well covered but the arms free, and everything disagree- able, as, for example, the sputum cup, should be put out of sight.
CHAPTER XIV.
How to OnsF.BYT., Report and Record Symptoms.
It is essential for a nurse from the beginning of her hospital work to cultivate the faculty of observation. In this not only the eyes, but also the hands, the ears, and even the nose, should all have a part, and this quality should extend not only to the particular symp- toms of her patients, but to every detail of the work pertaining to their welfare. In her first month in a hospital the beginner will probably succeed only in be- coming familiar with her surroundings, a few nursing appliances, and some of the minor steps in nursing ; and with the multitude of new duties which press upon her it is unlikely that she will be able to get any very clear ideas about the individual patients and their dis- eases. In her second and third months a more definite conception of her duties to the patients will gradually open up to her, and any general symptoms or con- ditions common to all sick people will one by one pre- sent themselves In her notice, to be followed gradually by s;. mptonis or conditions peculiar only to individuals or to particular diseases. Not all the observations concerning patients that a nurse must necessarily be conversant with can be grasped immediately ; they are only acquired through constant contact with illness, much practice, and the application of the principles which have been taught to her with reference to dis- eases and their phenomena. To some, who are en-
253
NURSMG
dowcd with quick instincts anil keenness of perception, this, knowledge comes much more readily than to oth- ers, who can acquire habits of observation and accu- racy of statement only by patience and perseverance. In the observation of symptoms there are three rules that a nurse should never lose sight of :
1. She should always observe minutely and accu-
rately the condition of her patient ;
2. These observations should be made according to
a regular system ami method;
3. She must learn to express the results of such ob-
servations in a clear and concise form, both
orally and in writing. It is very important that these three rules should be daily carried out in practice, as it is upon the nurse that the physician must for the most part depend for accurate statements regarding the condition of the patient during his absence. Frequently such observa- tions will assist him materially in making a corrc diagnosis and in the treatment of the disease. As w« said before, the reports should be given in a systematic, clear, and concise form ; they should contain an exact but simple statement of facts as they present them- selves, without any attempt at offering opinions or suggestions. A well-trained nurse is never guilty of attempting the diagnosis of a disease, even when invit- ed to do so. Her manner should be quiet and matter- of-fact, and she should not be too ready to take unto II any undue credit for doing only that which it is her duty to do. Her own work will also be made eas- ier for her in proportion to her ability to distinguish grave symptoms from unimportant ones, since she will frequently be placed in a position where she must de-
OBSICKVATIOX OF SYMPTOMS
255
cide whether the symptom.-. ;in sufficiently serious to require the calling in of a physician at an inconvenient time, or whether the instructions already given are sufficient to meet the requirements of the case.
Symptoms are either objective, those outward indi- cations or signs observed independently by the physi- cian, nurse, or any one under whose notice the patient comes, or subjective, those complained of by the pa- tient or elicited by inquiry from him. Both subjective and objective symptoms must lie remembered, but the patient's statements cannot always be fully relied upon, as ill people sometimes imagine their condition to be worse than it really is. and exaggerate their ailments, while clever malingerers, who arc only feigning iliness, are never at a loss for a pain or an ache. These state- ments, however, must be reported just as they arc given by the patient, as it is for the physician to decide which of the symptoms are real and which are simulated. In small children objective symptoms are relied upon almost entirely.
In a hospital the observation of a case should begin immediately after a patient comes under the nurse's care, and he continued during all the time he remains under it. The time may be divided into three periods: (i) that immediately following his admission; (2) that during which he is confined to bed; and (3) that of convalescence.
The first thing to be noted is the general appearance, whether the patient seems very ill and in great suffer- ing, or whether the indisposition is apparently only slight and not alarming. Besides this, attention is given to the sex, color, and approximate age, then to the manner or disposition, whether the patient seems
256
NUKSl.VG
to be quiet and orderly or rough and inclined to be troublesome ; any indications of weakness, such as in- ability to walk, awkwardness, or peculiarity of gait, should be noted, as well as any signs of deficient power in the trunk or in the arms. In examining into the condition of the mind we note whether the patient is conscious or unconscious, rational or irra- tional, depressed or hilarious, or whether he shows any signs of intoxication or delirium. The speech, too, should be observed: it may be "thick" or "clear," or there may be hoarseness; again, the patient may mutter or give vent to loud screams, according to tlic form of the delirium. The face and special senses are also very interesting ; thus the color of the skin may be bluish (cyanosis), pale, or jaundiced; the ex- pression may be one of pain; the eyes arc to be looked at particularly to see whether the pupils are dilated or contracted, and whether they arc equal or unequal in size. The pulse and temperature may be taken while these mptoms are being observed, and it should be remem- bered that all these points are to be noted in a quiet, unobtrusive manner, and as far as possible without the patient's knowledge. When the patient first enters the hospital any peculiarities of manner are apt to be ex- aggerated, and, u ire said before, the registered puba and temperature, owing to excitement and fear or to the unusual exertion necessitated by traveling, may not give us entirely reliable information. A nurse should do everything in her power by gentleness and attention to put a new patient at his ease, and in doing so she may very soon gain his confidence and learn imjK>rtant facts about his previous history that other-
OBSERVATION OF SYMPTOMS
257
wist- might not be found out either by herself or the physician. These first observations occupy only a few minutes, as a nurse familiar with her duties can pass from one detail to another with rapidity.
Further observations are made during the patient's bath, whether given in the tub or in bed, and before he is put to bed his weight should be taken. When in bed the general condition of the body is ascertained, and the existence or extent of any deformity, of obesity, emaciation, or cedema is noted ; the condition of the skin is next observed, whether it is hot and dry or cold and clammy, etc., or whether there are signs of any eruption, of bed-sores, ulcers, or any old or recent scars. Where such an examination is possible we should not fail to look for any peculiarities relating to the thorax or abdominal organs. The position the patient assumes, the extent and seat of any pain com- plained of, nausea or vomiting, cough, expectoration (its nature and amount), arc all important. Some in- formation on these points must be ready for the phy- sician on his first visit if he asks for them. In an hour or so after a patient has been put to bed and is quiet and composed, the pulse, temperature, and respiration should be taken again, as they are now likely to afford more reliable information than on admission.
The daily symptoms of a bed patient that must necessarily be noted may be best observed in conn.. tion with the different systems of the body, particular attention being paid to those which arc more especially implicated, but all Incident*] manifeslations must also be taken into account. The position which the patient assumes, the CApitWiOa <'f his face, restlessness, com- plaints of pain, the occurrence of haemorrhage, rigors, \1
the oomMMa of 1
of any of* ed. .Voc ail these, of every cue, bet rt is necessary that a dencaod something of the ngnifican
l .". ■ i of each
symptoms rnalre tnciiiicJics mannest.
The petition in bed a of importance, ai by it attention is often drawn to the organ affected, since the patient usual! y chooses, sometimes imoluntarilv. the position which causes the least pain and discomfort. In 'lipases of the heart or respiratory organs, there is difficulty in breathing, a sitting posture may be preferred, or if one lung is affected the patient will sometime* lie on that side in order to give the normal lunff as much freedom as possible, so that it may be better able to meet the increased work it is called upon to perform.
Dyipncea, or shortness of breath, occurs in various (ions, particularly in diseases of the lungs and bronchial tubes, and almost always in diseases of the heart, when the circulation in the lungs is impeded. r»css of breath is often a prominent symptom in certain stages of Bright's disease, and relieved breath- ing i* usually indicated by the patient's ability to lie down without a sense of discomfort or distress.
In abdominal diseases the patient may lie on the side, with the knees drawn up to relax the abdominal mus- cle* and thus relieve pressure: for this reason where theft is severe pain from peritonitis the patient will generally prefer to lie on the back with the knees drawn up, keeping as still as possible, since ever'/ ca- tion causes intense pin : in colic the patient is rcstlci-
OBSERVATION OF SYMPTOMS
259
anil turns frequently, preferring, however, for the most part, to lie on the abdomen, since he finds that pressure relieves the pain. Usually in fevers, as in typhoid fe- ver, the patient, if mil ms, lies quietly on his back, and is passive when turned from side to side; any attempt to move himself of Ml 0W0 accord is to be regarded as a favorable symptom. Where there is very great pain the patient is apt to be quiet, fearing the slightest movement, and in conditions of great weakness no effort is made to change the position. In some nervous diseases there may be continued rcst- Ii-nmic -.--, ;mil no |.iisili...ii i-. computable fur any length of time. As a fatal termination approaches, this sign is often very striking, being shown more especially by movements of the head, hands, and feet ; but this form is quite different from the ordinary restlessness Of illiusv, and is accompanied by other more impor- tant symptoms.
Pain. — Where there is a complaint of pain, as far as possible its nature and seat should be determined. Tain may be general or strictly localized; it may be continuous or come on in paroxysms. It may be dull and boring, or sharp, shooting, and throbbing. At the same time, as we have said, the condition of the pulse, the expression of the face, and the position of the patient in bed, should be noted and any further symp- toms recorded.
The appearance or expression of the face, to which we have more than once referred, should become a study to the nurse, for, coming as she does in contact with so many different people, she will find it of great use to be able to interpret correctly the different ex- pressions of the countenance both in health and dis-
a6o
NUftsrxG
Paleness of the face in an invalid, coming on suddenly, may be associated with faintness from haem- orrhage or some other serious cause, while a grad- ually increasing bluish appearance about the nostrils, lips and checks, is indicative of imperfect oxygenation, depending on some interference with the respiration or circulation. Its duration and degree should be noted. A "drawn" appearance about the lips and mouth ac- companies nausea, and excess of blood in the head is shown by a deeply-flushel, almost purplish-red color of the face. In pulmonary diseases there may be a char- acteristic flush or red spot on one cheek, not infrequent- ly on the same side as the affected lung. Besides these, there are tints peculiar to certain diseases. Thus we have often a waxy-white hue in Bright's disease, the bronzing in Addison's disease, the yellow skin in jaun- dice, the sallow complexion of opium habitues, and the dry, flushed face in fevers. The rash of some eruptive fevers appears first on the face, and its general ap- pearance, extent, and color should be observed.
The expression may lie indicative of marked changes in the course of the disease. A pinched, anxious look is often associated with a grave prognosis, and a dull, apathetic, expressionless countenance, like that so often seen in typhoid fever, is often significant of a serious illness. On the other hand, after the crisis of the dis- ease is passed the patient will often show by his calm and placid look that a marked improvement has taken place. Where there arc any signs of paralysis or im- pairment of the mental faculties, the nurse should note whether both sides of the face arc alike, or if the mobility is confined to one side or if one corner of the mouth is puffed out during expiration.
A
OBSE/ti'.-mox of symptoms
261
A rigor or chill is sometimes the first indication of an oncoming illness: it is an important symptom and must always be reported. The duration ami intensity of the chill may vary greatly, from a slight subjec- tive feeling of cold, lasting only a few minutes, to a pronounced fit of involuntary shivering, which may last for half an hour or more, and during which, in spite of all efforts to keep his body still, the patient is shaken, sometimes so violently as to move the bed on which he is lying. During this time the body may be externally cold and the face, lips, and finger-tips blue. The temperature should always be taken during a chill, and again half an hour after the chill has ceased ; during and after a severe chill there will probably be hyperpyrexia. These paroxysms occur in malarial fe- ver (when they may be severe and recurrent), at the beginning of other fevers, and in acute inflammations. When they occur in the course of any illness except malaria, they indicate the probable existence of some complicating process. The nurse should always re- cord the time at which a chill occurs, its duration, the degree of severity, and the patient's temperature during the paroxysm and after it has passed off.
In a case of lumorrha^e the source of the bleeding should be investigated, as well as the appi-aiana- >>f the blood, its color, whether it is fluid or coagulated or mixed with other substances, such as food. The quan- tity of blood lost should always be estimated
The number of hours a patient sleeps should be re corded in the written report, as the administration of narcotics will depend upon the amount of sleep ob- served by the nurse; a patient's own statements arc often very unreliable on this point. One should de-
262
NURSING
scribe whether the sleep is quiet or disturbed and rest- less, whether the patient sleeps lightly and is easily wakened, or whether he is aroused with difficulty.
The temperature, pulse, and respiration are always the chief guides, however, and they have been con- sidered by themselves elsewhere.
The condition of the tongue is an important symp- tom, as almost all diseased conditions have some action, direct or indirect, upon it. It may be pale and flabby, having marks of the teeth upon it, or bright red; or, again, it may present the appearance which is de- scribed as the "strawberry tongue" of scarlet fever. If the tongue is coated with fur, the color may be whitish or of varying shades of brown or black. The darker shades of fur are often present in the con- tinued fevers. The tongue usually cleans first at the edges, the process gradually advancing toward the centre ; a cleaning off in patches is held to be no good indication. We should notice whether it be dry or moist : the dry tongue occurs most frequently in fevers and in mouth-breathers. Any swelling, soreness or ulceration is also to be \vatcheil for. In observing the tongue the teeth .mr! gums and the odor of the breath should not be forgotten; if there be any accumulation of sordes about the teeth, or if they be loose, if the gums are sore and tender or bleed easily, a report should be made at once, especially if mercurials are being given.
Special Senses. — Taste. — When the tongue is out of order the sense of taste is often impaired or entirely absent. Certain diseases or the administration of cer- tain drugs may give rise to a characteristic taste in the mouth ; thus the patient sometimes becomes aware of a
OHSERVATION OF SYMPTOMS
^3
persistent metallic flavor while taking mercurial-, m elides, bromides, or arsenic ; a bitter taste is complained of in certain disorders of the digestion, and a salty taste in phthisis.
The Ears. — In disease the sense of hearing may be abnormally acute, especially in nervous troubles ; some drugs, particularly quinine, may produce temporary deafness. The occurrence of pain in the ear or any discharge from it, with the amount and character of such discharge, should be carefully recorded.
The Eyes. — In observing the eyes we should note the condition of the pupils. They may be dilated or con- tracted; they may react readily to light or their size may remain unchanged. The eyeball itself may be rolled from side to side or remain motionless. In some diseases we have protrusion of the eyeball; in others it may be sunken. The conjunctival reflex may be active, while in cases of complete unconscious- ness it is lost. Certain drugs affect tin- condition of the pupils, opium causing contraction and belladonna dilatation. Dilatation of the pupils is often present in meningitis.
The head i* often an index of the nature of the dis- ease ; it may be hot or cold, dry or moist and clammy, steady or tremulous. The power to grasp may be di- minished or absent. The character and shape of the finger.-, and the color of the tips and nails should also be noted.
Any departure from the normal in the condition of the skin should be watched for ; it may be too dry or too moist. Perspiration may be caused in illness cither by weakness or it may accompany a fall of tempera- ture. A high temperature with ■ damp skin indicates
a 64
NU/tS/.\'G
great weakness and is a grave symptom. Any pecu- liarity in the odor of the perspiration should be noted. Localized sweating is not uncommon in certain forms of nervous diseases.
In diseases of the respiratory organs the chief points to notice arc the cough, expectoration, rate of breath- ing, pain, and dyspnoea.
. Cough is the result of irritation in some part of the respiratory tract, and is often caused by some accu- mulation or occurs as the result of reflex irritation. The main points to notice about a cough arc its fre- quency and duration, whether it comes on in parox- ysms or is short, hacking, and difficult to control ; at What times of the day or night it seems to be worst, and whether it is brought on by lying down or moving about ; the amount and gross appearances of any ac- omipanying expectoration and the location of any pain MMCtttad with the cough should also be noted. Coughs may be described either as sharp and barking, as in some forms of hysteria, or deep and hollow, as in lung diseases ; then tin-re is the ringing, brassy cough which accompanies aneurisms of the aorta, and the peculiar laryngeal cough, which is high-pitched and superficial: besides these must be mentioned the characteristic croupy cough in children — a crowing sound produced by the spasmodic contraction of the glottis. The typ- ical convulsive paroxysm of whooping-cough, in which the sound is loud and barking and accompanied by a whoop heard soon after a long inspiration, will hardly be mistaken after the attention has once been called to it. If there is any expectoration, it may be mucoid — that is. clear and tenacious, somewhat like the white of egg; muco-purulcnt, a combination of mucus and pus;
OBSERVATION OF SYMPTOMS
l6$
or completely purulent, as in abscess of the lung. Again, it may be ropy and tenacious, or frothy, and may be streaked with blood. No sputum can be said to be characteristic of phthisis; the nummular or coin- shaped sputum occurs perhaps most commonly in chronic tuberculous disease of the limps. Now-a-days, by mean* of special staining methods and microscopical examination, physicians are able in three or four miti utcs to examine the sputum for tubercle bacilli, and if these an found, tin r<' ran Ik- no doulit of tin- existence of a tuberculous process. The bacilli arc found in greatest numbers in the minute, whitish, cheesy-like particles, about the size of a pin's head, so often seen in the sputum of phthisical patients. When the lung is gangrenous the sputum consists, as a rule, entirely of greenish pus, and has a v.i\ offensive odor. The sputum of pneumonia is often scanty, sometimes very tenacious, and at certain stages is intimately mixed with blood, which gives it a rusty color. The amount of blood may be great, producing the so-called prunc- jiu.v expectoration, in the pneumonia of drunkards or where the constitution has been much impaired. Measurements of the quantity should be accurately de- termined and recorded ; and if at any time the nature of the sputum appears to be changed, a specimen should be preserved for the inspection of the physician.
Dyspncca. palpitation of the heart, variation in the quality and frequency of the pulse, syncope and cedema may all be present as symptoms of disease of the heart: any one of them ma in connection
with other conditions. Palpitation is frequent not only in organic but also in functional diseases of the heart, and in dyspepsia, hysteria and nervous prostration.
*66
NURSING
Reliable information as to the condition of the ap- petite and the amount of food taken by a patient can be obtained only from the nursi ■'- uhscrvationf i the ex- act amounts taken, whether of solid or liquid foods, should be noted, and also the hours at which they were given. It should be noticed whether the food is eaten with a relish or only with an effort: some patients arc inclined to be ravenous, while in others the appetite is capricious, and can be tempted only by par- ticular forms of food. Any inclination to nausea or vomiting should be recorded.
When food is not retained the fact should be record- ed and reported, with the amount and character of the %'omitus. In some instances this may have peculiar characteristics; if so, it should be covered over and saved for the inspection of the physician. The color and odor of the rejected material are of importance, especially where there is any suspicion of intestinal ob- struction ; for where this is at all serious the contents of the intestine, not being able to pass by it. are forced back into the stomach, producing vomiting of faecal matter. Small quantities of blood may be changed in the stomach from a red to a dark-brown color by the action of the gastric juice, so that the vomited ma- terial has been described as "coffee-ground" vomit. The position and nature of any pain associated with vomiting, and any other symptoms occurring with it, should be inquired into.
Flatulence is the result of fermentation of the con- tents of the alimentary canal, with the production of gas; if these gases are not liberated in some way they accumulate until tln-n- i^ tympanites or distension of the abdomen ; this condition is recognized by the
OBSERVATION OF SYMPTOMS
267
hard, unyielding, resonant, distended abdomen, and for its relief the passing of a rectal tube is frequenth or- dered. In a general description of the evacuations from the bowels should lie mentioned the color, con- sistency, whether formed or liquid, the admixture or non-admixture of blood, mucus, or pus, the quantity, odor and frequency. The evacuations characteristic of certain diseases are described elsewhere. The urine should also be kept under daily observation.
The implication of the nervous system may be first shown by one or more of many various symptoms. Thus we may have incoherence of speech, rigidity, contortions of the face and body, twitchings, delirium, paralysis or coma. Most of these conditions arc treat- ed of in the general description of nervous diseases.
Delirium may be present as a complication in a great many diseases. Its general characteristics — whether it is active or quiet, busy or noisy, muttering or mani- acal— should be noted. Delirious patients should be kept under constant surveillance, as they frequently get out of bed, and arc liable to do themselves harm. When least expected, a delirium which has previously shown a low quiet muttering form may become loud and noisy or even maniacal. On the other hand, there may be merely a wandering of the mind, without any attempt to move — a symptom which sometimes occurs only during sleep.
Coma is also associated with many diseases, partic- ularly those of the kidneys and heart. It is a state of complete insensibility. In coma vigil the patient lies with the eyes wide open, but in a delirious, unconscious state; both arc very grave symptoms. In connection
268
NUftS/XG
with diseases in women the catamenia should be care- fully watched as to regularity, amount, color, and pain.
During the course of an acute illness some other disease may make it* appearance. This may be en- tirely independent of the first — for instance, an epileptic patient may have typhoid or malarial fever — or it may be connected with it. In the latter instance it is properly termed a "complication*' of the first affec- tion. In any severe fever certain complications — pneu- monia, bronchitis or acute kidney affections are liable to occur. In scarlet fever inflammation of the kid- neys must always be watched for.
Even symptoms which may appear trivial should be considered of sufficient importance to report, for when taken in connection with others they may be of great value.
For private duty or for a special patient, in addition to the twenty-four hours' record, a separate book ihotlld be kept in which all orders are written down. If such records are preserved by the nurse from the beginning of her nursing work she will in time find them of definite educational value.
In hospitals, regular books for the night reports should be kept. The day report can 1« given to the physician when he makes his daily visit, but the night nurse should make a brief and accurately written state- ment of each patient's condition during the night For patients who arc seriously ill a special written record for the twenty- four hours should be kept. The night report should be headed with the date, and each patient's name is to be written on the margin, a space of one or more lines being left between each. No re- marks should be allowed in this report beyond a clear
O/l.SFAT.ir/OA' OF SYAfl'TOMS
269
statement of facts founded upon observations such as wc have spoken of in this chapter, and at the end should be appended the nurse's signature.
The assistant nurses, appreciating the responsibility which rests upon their head nurse, should do all in their power to assist her by doing their work in the most thorough manner. They should understand that she must look to them for observation of many minor details of what is taking place in the ward. They should therefore be careful to report to her even what might seem to them unimportant symptoms or cir- cumstances. The head nurse should know everything that happens in her ward. The accomplishment of this should not be difficult, as each nurse has special work allotted to her. and her share of the responsibil- ity U strictly defined.
CHAPTER XV.
Tint Uum
The urinary organs consist of the kidneys, the ure- ters, the bladder, and the urethra. The kadlM the urine; the ureters convey it from the kidneys to the bladder, whence it is expelled through the urethra. Normal urine is a clear, watery, yellowish fluid, with an acid reaction and with a specific gravity of from 1018 to 1020: it is composed of water (in the propor- tion of 960 parts in 1000), inorganic salts, organic con- stituents, together with some coloring matter and a small amount of mucus. The more important inor- ganic salts are chloride of sodium, phosphate of potas- sium, and the sulphates of calcium and magnesium. The organic o n tiiuni-. arc chiefly urea and uric acid. The urine is an excretion ; that is to say, it is a fluid which carries off waste particles that would be harmful if left in the system. Two important waste substances of the body arc urea and carbonic-acid gas ; the former is given off by the kidneys, the latter by the lungs.
In speaking of the physical properties of urine we have to consider the quantity, color, odor, reaction, and specific gravity. The normal amount for an adult for the twenty- four hours is from 40 to 50 ounces or from 1200 to 1500 cc; for children between 2 and 5 years, 15 to 25 ounces; between 5 and 9 years, 25 to 35 ounces. The normal amount in health may be
a?o
THBJURISB I
IVfH
increased by drinking large quantities of fluids, espec- ially water, by diminished perspiration, and by emo- tional disturbances. The diseases which may increase the quantity of the urine are diabetes mellitus, diabetes insipidus, hysteria, convulsions, and certain forms of Bright's disease ; a temporary increase often marks the crisis in certain diseases — as in pneumonia. As a rule, where the quantity is large the color is pale and the specific gravity low. An exception to this will be found in diabetes mellitus, where the urine is usually clear, the color pale, but the specific gravity high, 1040 an J more, although enormous amounts of urine may be passed. Under normal conditions the quantity may be diminished where only small amounts of fluids are taken and where the perspiration is increased. The urine is diminished in amount in fevers, in profuse diarrhoeas, in certain forms of Bright"s disease, and in puerperal convulsions. The normal odor of urine is aromatic. The normal reaction is acid, but the urine in health may be faintly alkaline at certain times of the day. The first urine passed in the morning generally has an acid reaction, a relatively high specific gravity, and a dark color ; after a hearty meal it may be turbid, perhaps alkaline, and of a relatively low specific grav- ity.
To test the reaction litmus-paper is used ; acids change the blue color to red, alkalies the red to blue. When urine does not affect litmus-paper, it is said to be neutral. When it changes slightly the color of both the blue and red paper, it is said to be amphoteric :n reaction. It is more acid than usual in acute fevers and in rheumatism. Alkaline urine is of two kinds, the first being due to the presence of fixed alkalies,
*yi
MJRS/NC
the second to the presence of ammonia. Alkaline urine is always more or less turbid. If urine is kept in a warm place, it decomposes, with formation of car- bonate of ammonia; this decomposition is due to the breaking up of the urea as the result of the action ol micro-organisms. These organisms may obtain en- trance to the bladder from outside, and a cystitis may Ik caused, or if already present may be aggravated, by the passage of a catheter if antiseptic precautions are not taken.
Retention signifies the accumulation of urine in the bladder, with inability on the part of the patient to void it. Anuria or suppression refers to the failure on the part of the kidneys to secrete urine; in the latter case no urine will be found in the bladder. Incontin- ence of urine means inability to retain it in the bladder.
The color of urine may be spoken of as pale, color- less to pale yellow or straw-color, amber, high-colored, reddish-yellow, dark brownish, or blackish. The urine is pale in cases of hysteria, in diabetes, and also in that form of Hright's disease in which it is of low specific gravity ; the urine is high colored in febrile and inflam- matory complaints, and in some cases of indigestion. Rhubarb gives it a bright yellow or red color, bile im- parts a greenish tinge, carbolic acid gives it a dark brown color with the odor of carbolic acid.
By the specific gravity of urine we mean its weight as compared with that of an equal amount of distilled water. The normal specific gravity, reckoning that of distilled water to be 1000, is about loao. but may vary in health from 1015 to 1030. The siwcific grav- ity is determined by means of an instrument called a urinometer. Urine should be allowed to cool before
BkAMtNA r/o.v OF URINE
m
making the test. In health high-colored urine is of high specific gravity, pale urine is of low specific grav- ity.
In describing urine, the absence or presence of sediment should next be noted ; a sediment may have the appearance of a fine powder, or he ropy, viscid, or stringy ; we describe a sediment as flocculent when it appears in the form of soft flakes suspended in the specimen. In strictly normal urine no albumin is pres- ent. The presence of albumin does not OQCeNVtl] in dicate a disease of the kidneys ; thus there will be al- buminuria whenever there is blood or pus in the urin« — t. g. in cystitis or pyelitis.
The pupil should lean how to test for the presence of albumin, sugar, bile, phosphate! and urates, and to estimate the amount of the first two and of the urea. I'lus work is best done in the laboratory under a teach- er, each member of the class actually making the tests and observing the results.
The principal tests for albumin arc —
( i ) The Heat and Nitric- Acid Test. — Take a con- venient quantity of urine in a clean test-tube (where the urine is turbid it should be filtered before testing) and boil it ; if there is a large quantity of albumin pres- ent, it will be precipitated at once; add two or three drops of nitric acid, and if the precipitate remain the nen contains albumin. In acid urine the albu- min is precipitated below boiling temperature, but in alkaline urine the albumin may be held in solution after boiling, and acid is needed to precipitate it. If alka- line, neutral, or weakly acid urine gives a precipitate on boiling, this may be due to the presence of phos-
18
.SD
NUXSIXC
phatcs : if so, these will disappear after the addition of the acid.
(2) The second, and perhaps most common, test of all is the acetic-acid-and-heat test. The urine in a test- tube, if not already distinctly acid, is rendered so by the addition of one or two drops of dilute acetic acid. The upper stratum is now heated, and if there i* a precipitate, albumin is present.
(3) Heller's, or the Cold Nitric-acid, Test— Take a small quantity of nitric acid in a test-tube, and let the urine trickle, drop by drop from a pipette, down the side of the tube upon it ; if albumin is present, a while ring will form at the junction of the acid and urine. Occasionally a specimen rich in urea will show a ring of nitrate of urea, but in that case the white ring be- gins higher up than the point of junction, and floats off into the urine like a cloud ; such urine may be diluted until the specific gravity is 1005, and the test repeated. Further, the nitrate-of-urea ring will dissolve on heat- ing; the albumin ring will remain.
Tests for Sugar (glucose). —
(1) Trammer's Test. — To a given quantity of urine add one-third of its quantity of liquor potassae. and to this, drop by drop, a 10 per cent, solution of cupric .sulphate, until a precipitate begins to form; boil the mixture. If sugar is present, red oxide of copper will be precipitated. The test is not reliable for small quan- tities of sugar.
Fehting's test depends upon somewhat similar prin- ciples.
(2) The Fermentation Test.— A small piece of ordi- nary baker's yeast is put into a test-tube full of urine, which is placed month downward in a tray of mer-
F.XAMXATION OF VRINF.
275
cury. care being taken to prevent the urine from es- caping by covering the opening with the thumb u the tube is inverted. If sugar be present, fermentation begins, producing, among other things, carbonic-acid gas, which accumulates in the Upper part of the tube and gradually displaces the urine. A special apparatus of simple construction — the saccharimetcr — is now generally used for this purpose.
(3) Nylantler's Bismuth Test. — The following solu- tion is prepared : 2 parts of subnitratc of bismuth and 4 parts of Rochelle salts are dissolved in 100 parts of an 8 per cent, solution of caustic soda. Add 1 part of the Nylandcr's solution to 10 parts of urine. Mid boil together for a few minutes. If as much as one-tenth of 1 per cent, of sugar be present, the mixture turns black, owing to the formation of an oxide of bismuth. This is a very sharp test, and is probably the safest for general use. It must not be employed, however, when the urine contains albumin, as the latter substance forms a black sulphuret of bismuth.
Quantitative Test. — The amount of supar in a Riven specimen may be estimated cither by using Fchling's solution or by the saccharimetcr. a modification of the polariscopc. For the methods, text-books on the sub- ject must be consulted. When the total excretion of sugar or of urea is to be estimated it is necessary to collect and mix together all the urine passed in twenty- four hours.
Sediments. — If normal urine is allowed to stand for a time, a light flocculcnt sediment, composed of mucus and epithelial cells, becomes visible ; this is not abnor- mal. The so-called brick-dust deposits are made up of urates ; these occur in urine which is acid, high-colored.
276
JVVXS/JVG
and usually of a high specific gravity. They arc not uncommon even in health, and need not excite any alarm.
The test fur urates is that they disappear when the urine is heated. They are usually deposited in normal urine which has been allowed to stand in a cold room, and in larger quantities more especially in the urine of fevers and of acute articular rheumatism.
Uric acid occurs in crystals, and forms what is known as a cayenne-pepper deposit. Uric-acid crystals occur only in acid and highly concentrated urine. Sometimes they are passed in fresh urine. These crys- tals occasionally form the nucleus for a stone in the bladder.
Oxalurio is a term indicating the presence in the urine of a considerable quantity of oxalatc-of-lime crystals. They are either envelope-shaped or much more rarely dumbbell-shaped. The crystals of the triple phosphate of ammonium and magnesium arc present in alkaline urine, and may form a large pre- cipitate ; they disappear upon the addition of acid.
Bile in the urine gives to it a decided color so that when such urine is shaken the froth has a distinct yel- bwUfa tinge. A common chemical test for bile-pig- ment is as follows: A drop of urine is spread out on a white porcelain plate, and a drop of nitric acid (yellow with nitrous acid) is placed beside it. Where the urine and acid meet there will appear a play of colors if bile-pigment is present ; the colors produced arc green, violet, and red, the first being characteristic. This is known as Gmclin's test, but it is not always satisfactory.
The sediment in urine may be organized; thus it
EXAMINATION Of- URINE
h?
may contain epithelium, pus and blood-cells, tube-casts, accidental deposits, and bacteria. Small amounts of mucus and epithelium may be found in perfectly nor- mal urine; pus in the urine indicates inflammation of some portion of the urinary tract, and always calls for a careful examination. If the inflammation be in the urethra, most of the pus will be in the urine which is passed first, and it will be well to collect the urine in two vessels. A test for pus in the urine is to add liquor potasste ; if pus be present the deposit will be ropy and viscid. In alkaline urine, without the addi- tion of any chemical solution, such a precipitate will probably prove to be pus. Of course a microscopical examination is the best method of deciding as to the
nature of all such sediments.
To prepare a specimen of urine for examination, the bottle or glass used must first be sterilized; the urine is drawn directly into it, through a glass catheter if the patient be a woman, and the vessel stoppered with a plug of sterilized cotton or a perfectly clean cork. The vessel should be labelled with the name of the pa- tient, the date and the hour the urine was taken, and the full quantity passed in the twenty-four hours of which it is a specimen ; if it is from a ward, the name of the ward should also be added. The fresh specimen should be obtained bi fore bretkftst; that taken from the total amount of the twenty-four hours' urine will give more reliable information as to the average specific gravity, and consequently of the total amount of solids which arc being excreted. In all cases jars containing the urine should have been thoroughly cleansed, and must always be kept tightly covered.
Inflammation of the pelvis of the kidney is called
//WRStNG
Pyelitis; it may be caused by calculi, and renal colic may accompany it. No certain diagnosis can be made from the condition of the urine.
Haematitria is a name applied to the condition in which blood appears in the urine; the specimen will appear smoky, and red blood-corpuscles will be found on microscopical examination. The appearance of the urine varies according to the quantity of blood present.
llaemoglobinuria is characterized by the presence of blood-pigment in the urine, derived from the haemo- globin of the red blood-cells. The blood-cells them- selves are either absent or found in insignificant num- bers.
Uraemia is a diseased condition caused by retention in the blood of the waste substances which normally should be carried off by the kidneys; the symptoms may be very marked ; there may be intense headache, nausea, vomiting, severe twitchings, or even convul- sions and coma ; but in chronic cases these indications may be so slight that they may perhaps pass unnoticed before an examination of the urine has been made.
For retention, before resorting to catheterization, attempts should be made to have the urine normally expelled by means of hot applications over the region of the bladder; in women a hot Jponge placed over the vulva ,vill often have the desired effect. Sometimes hot water or ice-water is injected into the rectum, or water is allowed to run down over the pubes; or where retention is due to nervousness the mere sound of run- ning water may succeed in relieving the condition. If the uilN b dAwn by catheter, the operation should be repeated every six or eight hours according to direc- tions, and the bladder should never be allowed under
■INCONTINENCE OF URINE
/279V
any circumstances to go over twelve hours without being emptied.
Incontinence of urine will sometimes be due to over- distention of the bladder, and where this is the case catheterization will be indicated. When rubber urinals are ordered for incontinence, they should be washed out thoroughly at least twice in the twenty-four hours in a solution of hot water, soap, and borax. In fact, if at any time there be the least odor from them, they must be thoroughly scrubbed.
CHAPTER XVI.
Nursing in Genual Medical Diseases.
While it is quite understood that the diagnosis of ■e does not come within the province of the nurse's work, it is nevertheless necessary that she shall know enough about the various symptoms and their import to enable her to make correct reports and do good work, inasmuch as in the course of her work many of her duties call for special knowledge and the exercise of an intelligent judgment. In the pres- ent chapter some of the more common non-contagious diseases peculiar to the various systems of the body will he considered with special reference to the duties of the nurse in connection with them.
Tonsilitis. — Besides the common forms of sore throat which we term pharyngitis, and the rarer forms called laryngitis, we frequently meet with an acute or chronic inflammation of the tonsils. Here we find congestion and more or less swelling of the glands and the parts surrounding them. When in the acute form the process goes on to suppuration, the affection is popularly spoken of as quinsy. It begins with a more or less severe chill, accompanying the sore throat, and a temperature of from 1020 to 103* F., with head- ache and backache. A good cathartic and astringent and antiseptic gargles arc usually ordered, and when given early enough may cut short the disease. In
quinsy, where the pain is severe, applications of hot
280
ACUTE GASTRITIS
28l
water or of ice or poultices will give relief. In chil- dren the remedies to the inside of the throat arc ap- plied with a camel's-hair brush or swab. The patient should be kept in bed. as the disease rapidly exhausts the strength, and during convalescence a liberal diet should be given.
Acute gastritis denotes a condition often spoken of by a patient as a "bilious attack." In some cases it is caused by overloading the stomach with indigestible food, or comes on after drinking large quantities of alcohol. Furthermore, any irritant poison taken into the stomach may set up an acute gastritis. Vomiting, severe pain and tenderness over the epigastric region are the main symptoms. The patient may be very ill and death sometime* OCCara. He should be put to bed, all food should be withheld, and the physician summoned at once. For the pain counter-irritation may be used.
In cases of gastric ulcer the nurse should be on the look out for signs of perforation. Sudden severe pain, faintness, ■ quickened pulse and a sub-normal temperature arc all indications that should be rqrortcd at once and meanwhile the patient should be kept per- fectly quiet, not even being allowed to sit up in bed. /
Dyspepsia is a term commonly used to cover a num- ber of so-called functional diseases of the stomach. The patient complains of a sense of oppression and fulness — generally referred to the epigastric region — of pain, dull headache, and languor; he is irritable, and is often very much depressed. The symptoms vary in different persons, and sometimes in the same person at different times ; pain may come on Imme- diately after taking food or when the stomach is
282
ifURSfw;
empty, in which case it is relieved by eating. Regur- gitation or vomiting is a common symptom in cases of acidity caused by fermentation, ind flatulence and acid eructations arc frequent. Vertigo or dizziness is often caused by indigestion, and constipation is not seldom present. A nurse should report to the physician the appearance of any such symptoms, in order that the necessary restrictions or changes in the diet may be or- dered.
Diarrhoea means the frequent discharge of farce*, usually of a soft or fluid character. There are differ- ent varieties, the principal forms being the irritative, the symptomatic, the nervous, the chronic, and the choleraic.
Irritative diarrhoea usually lasts but a short time, and is often due to some disturbance in the intestinal digestion from over-indulgence in the matter of food or the eating of tainted meats. The chief symptoms, besides the frequent stools, arc more or less seven griping pains, nausea, weakness and, if tin disease h?s lasted long, great prostration.
Symptomatic diarrhoea occurs in the course of cer- tain diseases, such as typhoid fever, dysentery ami tu- berculous ulceration of the intestines. In the nervous form the intestinal digestion is disturbed by some strong mental emotion, anxiety, or fright. Chronic diarrhcra is often due to frequent or continued indi- gestion or to chronic inflammation or ulceration of the intestines. A looseness of the bowels preceding an at- tack of cholera may be mistaken in the beginning for a simple diarrhcea. A very severe form of diarrhoea, re- Hng true cholera and called cholera nostras, oc- curs in the summer months, and may follow a sudden
riiK/Toxrr/s
283
checking of perspiration, the abuse of iced drinks, ex- posure to sudden changes of temperature, or serious nervous disturbances. The attack usually begins at night with pain in the abdomen, vomiting and purging, and in grave forms there arc cramps in the lower ex- tremities and in the abdominal muscles. These symp- toms are accompanied bj profuse sweating, a weak pulse, and a condition of exhaustion, usually lasting a few hours and terminating rapidly in recovery.
The diet in diarrhoja should be carefully regulated albumen water, sterilized milk, or milk and lime-water, may be ordered at first, and afterwards the more easily digested solid foods, fruits and vegetables being pro- hibited entirely even for some days after convalescence. Rest in bed is a valuable adjunct to the treatment. Colonic flushings are sometimes ordered.
The name appendicitis is given to an inflammatory condition of the vermiform appendix, which may result in ulceration, perforation, and abscess-formation. The chief symptom is severe pain in the rifjht iliac region, often associated with vomiting and obstinate consti- pation, localized tenderness on pressure, and elevation of temperature. Perforation with a resulting general peritonitis is an accident to be dreaded. Purgatives should never be given. Until medical aid can be ob- tained the patient should be kept perfectly quiet in bed, with an ice-bag placed over the seat of p;iin
Peritonitis is an inflammation of the peritoneum which may be due to extension of inflammation from any of the organs covered by it or to perforation from an ulcer of the stomach or bowels. It is more especial- ly to be feared after sur.L-ii -.,! operations on the abdo- men if the wound has I" en allowed to become infected.
284
Mt/tS/NC
J
k.
The main symptoms arc severe pain, the patient lying on the back with the knees drawn up and -li.,nlki- btinched up; there is tenderness on pressure over the abdomen, which is generally distended ; the respirations are frequent and shallow, the pulse is rapid, small, and wiry; the temperature moderately high; vomiting be- gins early, the expression changes greatly and the face takes on ati anxious and haggard look. The patient should be kept very quiet, and all pressure from the bed-clothes avoided by the use of a cradle. In peri- tonitis following perforation, immediate surgical inter- ference is usually indicated. If opium is ordered for the pain, the effect should be carefully watched, as unconsciousness may be induced, from which it is hard to arouse the patient. Hot or cold applications to the abdomen are also used to relieve the pain. Crushed ice or soda water may be given for the vom- iting. The rectal tube may be passed to relieve the accumulation of gas. To remove fermenting material an enema may be ordered.
By ascites is meant a collection of fluid in the peri- toneal cavity. The abdomen is sometimes tapped if the amount of fluid be large. When this is to be done the instruments must be sterilized and the abdomen prepared, so that the danger of introducing septic material will l>e avoided. A small occlusive dressing should be ready for application after the operation.
Bronchitis is an inflammation of the bronchial tubes. It is usually due to sudden changes of temperature, exposure to damp and cold, over-fatigue, ovcr-hcated rooms, together with improper food. In the young and in elderly persons it is always to be regarded as a serious affection. The acute form begins as an ordi-
PNEUMONIA
*%$
nary cold, which extends to the bronchi, giving rise to a sense of tightness and oppression in the chest. The cough at the onset is dry or is accompanied by but little expectoration, which at first is mucoid in character, but later becomes more copious, and is often purulent ; the pulse is quickened and the temperature .1 little elevated Immediate care is. needed; the pa- tient should be kept in bed in a moderately wcll-vcntilat- cd room, an even temperatui maintained, and :i
mustard foot-bath and hot drinks may be given. In- halations of steam and keeping the air of the room moist will relieve the feeling of oppression and the pain. The bowels should be kept open, and plenty of light nourishing food given. Mild cases recover in a few days, but in all the possibility of dangerous com- plications should be kept in mind and constant watchful care is necessary from the onset until the patient is quite well.
Asthma. — The most common form of asthma is a bronchial affection characterized by cough, dyspnoea, and expectoration of a mucous secretion, the attacks occurring pafoxysmally. Although rarely dangerous, it is a very distressing disorder, and in a severe attack the symptoms may be alarming. Asthmatic subjects usually carry remedies with them, such as capsules of nitrite of amyl, which they break in a handkerchief for inhalation ; these should never be used except by order of the physician. The patient should have all the fresh air possible, and a hot foot-bath and hot drinks may help to give him relu 1
Croupous pneumonia is an infectious disease due to a micro-organism which locally produces an acute in- flammation of the lung-substance, and constitutionally
l86
XCA'SJiVG
a condition of prostration, resulting from absorption into the blood of the poisons produced by the bacteria. It is a serious condition, and is especially fatal in the cue of old people and in individuals who have been accustomed to the excessive use of alcoholic stimulants. It is divided into three stages: the first is the stage of engorgement ; the second, that of consolidation ; and the third, that of resolution. The lower lobe of the right lung is most frequently attacked : in the so-called double pneumonia both lungs are involved. Anything that tends to depress the vital powers, such as faulty hygienic surroundings, exposure to cold, and particu- larly to sudden variations in temperature may act as a disposing cause. The onset is sudden: the pa- tient lias a chill, complains of a sharp pain in the side, and the temperature rapidly rises. The respirations arc quickened to 30 or 40 or more per minute: the breathing is difficult; the face is flushed, particularly the cheeks; with each inspiration the nostrils dilate; the cough is short and hacking; the expectoration at first may be frothy and mixed with mucus, after- ward becoming thick, tenacious, and of a rusty-red color, due to its admixture with red blood-corpuscles. In alcoholics $0 much blood may be mixed with the Npiitum :is (o give it a dark reddish-black color; this is the "prune-juice sputum." When resolution takes place, the expectoration becomes light yellow in color and more abundant Through the course of the dis- ease the ti-mpcraturc ranges from 102" to 104* or 1(15* F., being a little lower in the morning than in the tVWliDgi A sudden fall as early as the third or as Lite as the twelfth day, accompanied by profuse perspira- tion, indicates the crisis, after which convalescence
r.\F.UMONIA
287
begins. The pulse is full and rapid, varying in fre- quency from 90 to 120 beats per minute; in severe cases it may even exceed this. Delirium may be present from the beginning, and the patient, who may try to get out of bed, must be carefully watched For this symptom the ice-bag to the head or the cold pack is often ordered. It is necessary that th< nurse make accurate statements to the physician with regard to the pulse, temperature, respiration, and spu- tum : the last mentioned should be kept for inspection. She must also be able to describe the symptoms, to note any serious change in the condition of her pa- tient, and to understand its significance. The ventila- tion of the room should be carefully regulated, the temperature being kept at 68c F. The mouth must be especially cared for; when there has been a profuse perspiration the clothes should be changed at once, the body should be sponged in water and alcohol, and warm, dry clothes put on. The diet during the fever should be liquid but concentrated, in order to supply plenty of nourishment. It is best given at frequent intervals: much depends upon the keeping up of the strength of the general system, as heart failure is not uncommon. Some form of alcohol is frequently ordered throughout the course of the dis- • im , when ihc condition of the heart indicates its use. For the pain the ice-bag, the ice-poultice, or dry heat is applied over the affected side. To reduce high temperature, the cold pack, cold sponging or the tub-bath at 70° F. with friction, is often ordered. When they are employed, care must be taken to keep the hands and feet warm. In the case of a child under three years of age the temperature may be re-
?KK
NUftSLVG
dnccd by means of the full-hath given in the following way: The child is laid on a sheet which lias been spread over the tub and is lowered down, until the sheet forms a sort of hammock which will contain sufficient inter to cover the whole body. The dura- tion of the bath should be about eight minutes at a temperature varying according to the height of the fever and the condition of the patient. For older chil- dren the compress is preferable, as it saves resistance on the part of the patient. Ice-bags are sometimes applied to the abdomen to reduce the temperature. These procedures not only lessen the fever, but also stimulate the nervous centres and thus improve the respiration and circulation, while at the same time they exert a good effect on the cough and expectoration.
Oxygen is often employed in cases of pneumonia, in poisoning from deleterious gases and other con- ditions. The gas is contained in a heavy cylinder which can Ik- brought to the 1-.-:'.. The tl- •••■.- is regulated by means of a stop-cock and the gas is conducted from the cylinder through rubber tubing into a glass flask half filled with water, through which it is allowed to bubble gently and then is directed through another length of tubing towards the patient. If the patient is strong enough he inhale* the gas through B glass nozzle placed between his teeth, but for unconscious and very sick individuals a funnel is held over the mouth and nostrils. The effect is care- fully watched, the flow of gas being restricted or the I removed further away if any distress becomes apparent. Thus far the serum treatment of pneumo- nia lias not proven efficacious.
I'Uurisv is an inflammation of the two surfaces of
PLEURISY
289
the serous membrane which surrounds the lungs. It may be localized or general, dry or accompanied with effusion. When the inflammation begins there is a sharp shooting pain, the "stitch in the side," which is aggravated by breathing or in fact by any movement. The pain is caused by the friction or rubbing over each other of the surfaces of the pleura which have been roughened by inflammation. An exudation (the amount and consistence differing in different cases) next takes place. Together with the sharp pain in the side, which is relieved as the exudation increases and forces the inflamed areas apart, the patient may have a slight chill ; the respirations arc hurried and shallow, the patient fearing to take a deep breath on account of the ptifl ; the temperature is elevated, and there is a short, dry cough, but little if any expectoration. The patient should be kept quiet, being propped in the po- sition that will give the greatest amount of comfort. Where there is much effusion a dry nutritious diet is given, the amount of liquids being restricted. A light bandage applied around the thorax or rubber strapping extending over about two-thirds of its circumference lessens the pain by diminishing the expansion of the chest on the affected side. The straps should be three inches wide and long enough to reach about two-thirds around the cheat They arc put on tightly after a full expiration, and follow the direction of the ribs. The lowest Strap is applied first and each subsequent one is allowed to overlap the one beneath it by about an inch. An ice-bag may be kept over the seat of pain. As a counter-irritant the Paquclin cautery may be ap- plied or mustard plasters or iodine used. To reduce the amount of effusion the phvsician orders Epsom salts
290
NURSIXG
or some other hydragogue cathartic. When the cav- ity becomes much distended with fluid, aspiration is performed. Sometimes the exudation becomes puru- lent, and tin- conditinn is then spoken of as purulent pleurisy or empyema.
A total loss of power in some of the muscles of the body is called paralysis; when the loss is only partial we have what i> called a mmlitioii of paresis. Ss^ Hemiplegia means a paralysis by which one whole side of the body is affected. When one limb or one sot of muscles only is paralyzed the term monoplegia is used. By paraplegia we means a loss of power in both arms or both legs. By complete paraplegia is meant paralysis of all four extremities.
These paralyses may l>e due to various causes — to lesions of the brain, of the spinal cord, or of the peripheral nerves. In most cases hemiplegia is due to thrombosis, eml>olism, or the rupture of a blood-vessel in one of the hemispheres of the brain.
Where there are muscular spasms or convulsions •lie nurse should watch carefully to see what part of the body is first affected, since this knowledge may help the physician in localizing the seat of origin of the disease.
With good hygienic surroundings, good nursing, massage, and electricity, complete or partial recovery in some forms of paralysis may take place ; great care must be taken to guard against bed-sores.
Tabes, or locomotor ataxia, is characterized by a loss of co-ordination in the legs without any marked loss of power in the muscles. It is not a very rare disease. The gait is unsteady, because the patient is not able to tell unconsciously, as he naturally would do, how
MENINGITIS
291
his muscles arc acting, but has to be guided by his eyesight. As a consequence, walking in the dark is particularly difficult. Attacks of sharp shooting pains, which are termed "lightning pains," often occur in the legs or other parts of the body. Attacks of vomiting and pains in the stomach — the so-called gas- tric crises — arc sometimes met with. By looking after the genera! comfort of the patient, the nurse can do much toward making his life bearable, and besides this he needs encouragement to make him persevere con- scientiously with the treatment prescribed
Tuberculous meningitis.. The most common form of meningitis with which the nurse will meet is due to
tuiiiTcuiosii and b not ran In cbfltbwt Meningitis may also occm as a complication of pneumonia and other acute diseases.
CcrcbrO' spinal Meningitis or spotted fei'cr is due to a specific organism, the BW uingo-coccus btftcelhi laris. The meninges arc the membranes which en- velop the brain and spinal cord, and rm •mm. inflammation of these membranes. The acute form occurs most often in childhood, but adults arc also attacked. There are usually sudden violent headache, severe pain, vomiting, an occasional sharp peculiar cry, great restlessness, and sometimes convulsions. A char- acteristic rash is often present and berpea is not un- common. There may be fever, and usually in the beginning there is a chill. In the second stage the pulse is often slow. As these symptoms are aggra- vated by bright light and loud noises, the nurse should •ier that her path nl is kept quiet, the light subdued, and all visitors kept from the room. Where the house is near a busy and noisy street it may be necessary in
XURS/1VG
lib* *mi other diseases to cover the roadway with saw- dtMfc Noiseless shoes must he worn by all the attend* »ud the slamming of doors and other unnecessary i»v»»m I. The paticm ihoilld be isolated, an ice-
c i .impresses should be applied to the head. « bowels kept well opened. The fever may be re- told spongings. If the vomiting is obstinate, iinata may be necdc<l to keep up the nutrition, •utiiiuous tub-bath has of late been used with ■god effect. Diphtheria antitoxin has been recom-
ij means a sharp pain in the course or
button of a sensory nerve and is caused by some uiuiion direct or indirect Among some of the ex- citing causes we may mention exposure to damp and
chronic poisonings, decayed teeth, dyspepsia, con- iii|>.nion, malaria, or a severe strain of any kind. The
may assume a variety of forms. One of the iK-rves most commonly attacked is the trigeminus, or fifth cranial nerve. When the pain in this nerve is associated with sharp spasms the affection is called Ik douloureux. Sciatica may be ilue either to a neu- ralgia or to an inflammation in the sciatic nerve. In most forms of neuralgia the diet should be especially nourishing, in order to improve the general condition of the system
Delirium tremens results from poisoning from the excessive and frequent use of alcoholic stimulants. In the beginning there are depression and anxiety, slecp-
H ind muscular tremor, with a weak and feeble pulse. After a few days delusions and hallucinations appear, and in the paroxysms of fear or fury thus induced the patient may become dangerous and attack
CAHDIAC DISEASE
*93
his attendants. When he is violent the assistance of male helpers is necessary. Aggravated insomnia is a bad symptom, and if sleep cannot be obtained the termination is usually fatal. The bowels should be carefully regulated. In some cases tub-baths arc or- dered and forced feeding may become necessary. The patient should be kept in a large room, with the windows and doors guarded and the light subdued.
Cardiac Disease. — Diseases of the heart are diag- nosed by physicians chiefly by means of physical signs obtained by inspection, palpation, percussion, and aus- cultation: with these, of course, the nurse has noth- ing to do, but she will be interested in noticing some of the general symptoms which occur and which can be remembered only after long observation at the bed- side. The most frequent disorders of the heart met with arc inflammation, valvular disease, angina pec- toris and dilatation.
Heart disease is frequently a sequela to other dis- eases, such as acute rheumatism, or follows acute in- fectious diseases as pneumonia, typhoid fever, diph- theria, or Blight's disease.
Pericarditis is an inflammation of the pericardium or the membrane that envelops the heart. Endocarditis is an inflammation of the lining of the internal surface of the heart. The origin of both diseases can often be traced to an attack of rheumatism or chorea, of the valvular diseases of the heart, where changes in the valves have taken place which cause obstruction to the flow of blood through them, or on account of im- perfect closure permit of a backward current, are due to chronic inflammation of the endocardium. Where the valve is thickened and there is obstruction to
the onward now of Wood, we have a mnomt, aortic stenosis), and in these the ral vn leak, whereas normally they should tightly, the valve is said to be insufficient (mitral re- gurgitation or msuftciency. aortic regurgitation or tn- f). A patient with heart <hse-sw? nay often
go on for yean without being aware of its existence, (bough at times he may notice that he is somewhat short of breath. As a rule, it is not until the heart is becoming exhausted that serious symptoms begin to show themselves, although, of course, such a patient sometimes dies suddenly if too much strain is put upon the heart by over-excrtioo or emotion. The appear- ance of a patient suffering from a grave heart affection is usually very striking when he comes into the ward. I f #• it often very short of breath ; his face may pre- sent a bluish appearance (cyanosis) ; the legs arc often much swollen, ;in<l the swelling max affect the arms, hands, and other parts of the body (oedema). Be- sides the proper remedies, he will probably be ordered a liquid or very light diet and absolute rest in bed. If hr ratlin t lie down, a bed-rest must be provided, or he may be propped up with a sufficient numlwr of pillows. ii many cases the heart will thus be enabled to re- • opt rate, so that it can do its work fairly well for a long time. All Hidden m and excitement of
Ittld be avoided. The patients, especial- ly when they are getting better, are often very much averse to staying in bed, and the nurse will have to exercise a great deal of tact, combined with iron firm- nets, in Ordot tint the treatment may lie thoroughly carrird Out I'd filiation is a symptom rather than a disease; the
DROPSY
195
patients complaining of a fluttering or an abnormally rapid beating of the heart, which disturbs them very much. It is often seen in nervous individuals or in those suffering from indigestion or amemia, and fre- quently gives rise to unnecessary alarm. It must be remembered that while this symptom may occur in or- ganic disease of the heart, it is by no means a sign of the latter.
Angina pectoris is characterized by a sudden agon- izing pain in the region of the heart which extends down the arm and across the sternum. The patient grows pale, utters a cry of pain, and fears that he is going to die ; and in fact a fatal termination does sometimes occur. The condition is serious and a phy- sician should be summoned at once.
In all these diseases precautions should be taken to keep the patient perfectly quiet, and to guard against MBCitenknt and WOTTJI -i-. much ;is |»—.iUi. A proper diet is of the first importance.
Oedema or dropsy is a condition very common in Cardiac and renal disease and in many anaemic states. It is a condition in which the blood serum escapes through the walls of the capillaries into the loose tis- sues which surround the vessels. Similarly we may- have a collection of fluid in any of the cavities of the body such as the pleura or pericardium.
Where fluid is present in the sulx-utaneous tissues it can be recognized by pressure on the skin, the hole or "pit" made bj the Rngi r ]» raistiog after the latter is withdrawn. Fluid in the serous cavities of the body can be recognized only by special methods of in vestigation.
More or less localized oedema may be present in
196 NVKSiSG
i enndxtions as. {or instance, as a rook of I or aneurism. In ovombottfl the Mood and forms a dot in a vessel whereby the pningc of blood is obstructed. In some eptdenncs of typhoid venous thrombosis is quite common, the ressd ob- structed usually being the femoral vein. It is not an uncommon complication in septicaemia and in poer- peral infection.
In tnyxoedema, which is due to atrophy of the thy- m|d gland, the skin of the face becomes pale and swol- len, bat does not pit on pressure.
In all cases of dropsy the patient should be kept quiet ami in bed ; flannel must be applied over the swollen parts for warmth. If the cedema is in the lower cx- thould be carefully bandaged.
Bright"* disease of the kidneys, assumes several forms, and may be acute or chronic The symptoms may be divided into two groups, (a) those due to the presence of albumin in the urine (albuminuria), which means the loss of albumin from the blood, (b) those attributable to urxmia, a condition due to the presence of poisonous substances circulating in the blood, (a) The loss of albuminous substances which should be re- tained in the body for its nutrition* leads to impoverish- ment of tli>' blood and tissues and gradually to exhaus- tion of the vital functions, (b) In urxmic conditions .ticnt often complains of a persistent dull, heavy headache, dyspnoea and giddiness. Vomiting and drowsiness arc often present. The patient may become delirious or have convulsions and pass into a state of coma doling which death often ensues. In acute ne- phritil that is an inflammation which comes on sud- denly and may be the result of exposure to cold or oc-
BRIGHT S DISEASE
297
cur as a complication in some of the infectious fevers, particularly scarlet fever, or after the employment of certain toxic agents, such as cantharides or turpentine. The most prominent symptom is a peculiar palenes* of the skin, accompanied by dropsy, the swelling being first noticed about the face, eyes and ankles. There may, however, be a very severe kidney disease without much u-dema. t In inyh headache, nausea, and oilier ur;e mic symptoms will generally be present. The quantity of urine is diminished or there may be total suppres- sion; albumin is always present; the amount of urea excreted is lessened, and casts of the urinifcrous tubules arc found on microscopical examination. Every effort should be made to keep the skin and bowels active. The patient should be kept in bed between blankets. The diet should be milk diluted with barley-water. Any muscular twitchings should l>e at once reported since they may be the precursors of uremic convulsions. The physician may order a sweat bath first and plenty of cream-of-tartar water to drink, which the nurse will make by dissolving a drachm of cream of tartar in a pint of boiling water, and adding the juice of half a lemon and a little sugar ; this is to be given cold. Ex- posure to draughts and sudden changes of temperature should be guarded against.
In the chronic form which may last for many years, the quantity of urine is often increased, the specific gravity is generally low, and in many case* only n trace of albumin is demonstrable.
A record of the amount of urine passed in the twen- ty-four hours will often be of great assistance »o the physician in his treatment of the case in almost an>
*9&
NURSING
disease, but where the kidneys are implicated such a daily record should be considered indispensable.
Acute articular rheumatism, or, as it is often called, rheumatic fever, is one of the most painful affections which will come under the care of the nurse. Owing to the complications and the after-effects of an attack of rheumatism, it must always be looked upon as a formidable disease.
The acute form begins with a feeling of malaise, often with sore throat, with more or less severe pain in the joints, and with fever, the temperature ranging from 102" to 104° F. The joints become swollen, hot, red, and very painful to the touch or upon the slightest movement ; the perspiration is profuse, and has a characteristic sour odor ; the urine is strong- ly acid, highly-colored, and scanty. The bed should be made up with flannel sheets above and below, and the patient should wear a loose flannel gown which opens down the front and has large sleeves, so that it can be changed easily, without giving him unnecessary pain, whenever it becomes damp with sweat. He should have a daily sponge-bath (between blankets) of alcohol and hot water; he may be turned gently from side to side, but should not be moved more than is absolutely necessary. In milder cases the wrapping of the affected joints in absorbent cotton will often be sufficient to render the patient comfortable. Where, however, there is great pain, although hot applications are usually ordered, the patient sometimes prefers ice- cold compresses which are kept constantly saturated with ice-water until the swelling and pain have sub- sided. Hot compresses saturated with Fuller's solu- tion (carbonate of sodium, 6 drachms; laudanum, 1
DIABETES MELUTVS
299
Ounce; glycerin, 2 ounces; water, 9 ounces) are often very effective. To keep the parts absolutely quiet, splints arc sometimes ordered ; they should be well padded and applied with moderate firmness. Friction is not well borne until the acute stage has been passed. For high fever the cold bath or the cold pack are sometimes ordered. The diet consists chiefly of milk with alkaline mineral waters. Lemonade, not too sweet, oatmeal-water and barh'v-waift may .il-.o he given. Gradually the diet is increased, but for a time should consist mainly of milk and vegetables. Even in convalescence meat should be used very sparingly.
In the chronic forms of rheumatism much relief is afforded by a careful and long-continued massage treatment. a
Diabetes melliius is a disease characterized by trie excretion of an enormous amount of urine containing glucose or grape-sugar. The amount of urine in twenty-four hours may measure from six to thirty pint*, or even more, according to the severity of the case. The specific gravity is high. There are grad- ual emaciation and loss of strength, great thirst and a ravenous appetite. Care in the diet and hygienic measures are important factors in the treatment. Die- taries for diabetic patients have been especially pre- pared, and should be strictly adhered to. Foods con- taining sugar and starch arc not allowed except in very limited quantities. The action of the skin should be especially cared for, and unless the patient be too weak or the cedema be marked, a moderate amount of exercise should be taken daily, or massage may be substituted for it. An equable temperature is to be maintained, and freedom from excitement guarded
JOO
NURSING
against. Tlie sign* «f improvement arc a gain in ht, a moist skin, less thirst, and a diminMied i|uan- iit\ >if urine containing a Miiallcr quantity of sugar ant', having a lower specific gravity. The quantity of urine passed, its specific gravity and the amount of sugar present should be recorded daily. The patient should alio he weighed once a week.
In diabetes insipidus a superabundance of normal urine of low specific gravity is excreted. It occurs most often in young people, and may be congenital. Sometimes such cases may persist for years without any deterioration in health. It is a disease of nerv- ous origin, but its nature is unknown.
Hydrophobia is an acute disease of animals, depend- ent upon a specific virus and communicated by inocu- laii'.n Ufualfy by the bite of a mad animal, to man. A variable time elapses between the introduction of the poison and the appearance of the symptoms. The incubation is shorter in children than in adults. Ra- pidity of onset of the symptoms is determined mainly by the part of the body which may happen to have been bitten. Wounds about the face and bead arc especially serious. Those on the hands arc next in Puncture wounds arc the most dangerous. Lacerations are fatal in proportion to the extent of the surface afforded for the absorption of the vims. The average incubation period is from six weeks to two months, although it may be longer.
The first symptom may be irritation about the scar, or pain or numbness with depression and melancholia, headache and loss of appetii Bright light or
arc distressing, and difficulty in swallowing is complained of. There may be some increase in the
the ni.oon
301
temperature and pulse rate. In the next Stage there are great excitability and restlessness, usually accom- panied by violent reflex spasms. Any attempt to take water is followed by a painful spasm of the muscles of the larynx. This is why the patient dreads the sight of water, and this symptom has given the name hydrophobia to the disease.
The bite should be carefully washed and thoroughly cauterized with pure carbolic acid or caustic potash. The wound should be kept open for the first few weeks. In all cases in which it is probable that the dog has had hydrophobia, treatment by Pasteur's meth- od is. indicated. If SymptORU of the disease appear, the patient should be kept very quiet in a darkened room, and allowed to sec only the nurse and physician. Chloroform and morphin are given for the spasms. Sometimes cocain is applied to the throat to reduce the scn.Mtiveiu.ss and enable the patient to take liquid nourishment. Xutritivc encmata arc usually ordered.
The examination of the blood plays an important part in the diagnosis of disease. The outer surface of the lobe of the car is usually selected for making the puncture, and is thoroughly cleansed with soap and water, and then with sterile water. 1'rom the needle puncture a drop of blood is obtained which is placed on a coverslip. and examined by the aid of the micro- scope.
In the various forms of anaemia, the blood drop definite changes which can be recognized by the expert. The so-called primary anaemias are due to disorders of the bloodmaking organs; the secondary amemiaa are usually associated with some other acute or chronic disease. In anxmia there is usually pallor
302
NURSING
of the face, gums, and conjunctivae, with a gradual loss of strength. The symptoms will depend upon the particular disease which has produced the anaemia. Proper food, with pure air (either in the mountains or at the seaside) together with careful nursing and some preparation of iron or arsenic by the mouth is the usual treatment that is prescribed. In "pernicious an- aemia" the ultimate outlook is bad. In this form the stomach, intestines and spinal cord are often affected. Extreme prostration results and finally causes death.
CHAPTER XVII.
Medical Emergencies— Artificial Respiration.— Drowning. —Poisons.— Medical Appliances.— Medical Rounds.
Under the head of medical emergencies may be classed conditions of unconsciousness, such as syn- cope, hysterical, epileptic, and apoplectic attacks, acute alcoholism, sun-stroke, drowning, and poisoning.
Syncope, or unconsciousness, is often seen, in a mild form, in what is commonly called a "fainting fit." The condition is generally due to some disturbance in the circulation, and often follows a transient anemia of the brain. It is apt to come on suddenly, and is not a serious condition unless the attacks an* often re- peated, in which case one would suspect the existence of some disease of the heart or blood-vessels. The patient should be put in the recumbent position, with the head lower than the rest of the body, so that the blood may flow more quickly to the brain : this, in addition to loosening the clothes about the neck and upper part of the body and allowing the free access of pure air, is usually sufficient. The respiratory movements may be stimulated to action by holding for a few seconds aqua ammonia or some smelling salts near the nose, although here we must warn against the danger of holding strong ammonia too close to the nostrils of an unconscious patient. If recovery does DOl take place almost immediately, external waimth
should be applied and medical aid sent for.
an
3<H
nuksim:
Care should he taken not to fainting with
that form of hysteria in which the patient lies appar- ently unconscious: the latter may be recognized in that the pulse-rate will be normal, and if an attemr. is made to raise the eyelid the patient will resist and close it again; the body will feel warm, and theft will he little if any change in the color of the face. For hysterical patients it is best to remain near them while the attack lasts, but to leave them undisturbed until they recover.
Bpiltpty should properly be discussed under nervous diseases, as it is due to a disordered condition of the brain. Since, however, epileptic convulsions are of very frequent occurrence, and may come on at any- time or place, the nurse may be almost certain of some- where being confronted with an attack, and it is very necessary for her to know what to do and what not to do for the sufferer. The "fit," as it is commonly termed, is characterized by well-defined symptom; the patient, sometimes after uttering a peculiar cry. but often without giving the slightest indication to the bystanders that anything is wrong, suddenly falls to the ground, where he lies unconscious. The mast li- ne rigid (tonic spasm), the eyes arc fixed, and the pupils often dilated. In some, but not in all, cases there is frothing at the mouth. After a few seconds the muscles In-come relaxed, and the tonic spasm is followed by twitchings and jcrkings of the whole body (clonic spasm). Tlie attack lasts only three or four minutes, after which the patient either becomes com- pletely conscious and may go about his business at once, or on coming to is vers irritable or seems di and goes off into a deep sleep. The only relief that an
APOl'LEXT
30$
on-looker can give is to place the patient on his back with the head slightly raised, loosen any tight clothes, and see that he docs not hurt himself: he should be allowed a free supply of air, and something should be placed between the teeth to keep him from biting his tongue A lead pencil or a piece of wood wrapped in a handkerchief can always be obtained, and will every purpose. No attempt should be made to stop the movements.
The so-called apoplectic fit is usually caused by haemorrhage into the brain substance. A person sud- denly, or after some slight premonition, falls and be- come* unconscious ; the face takes on a deep purplish flush or grayish-pale color, the pulse is full and slow, and the breathing stertorous. The pupils may be di- lated and unequal. Tin- patient should Ik- put in a semi-recumbent position, all tight clothing should be loosened, especially about the neck, and cold applica- tions should be made to the head, while dry heat in some form is applied to the trunk or extremities. Stim- ulants must not be given, and the room should be kepi cool, dark, and quiet
Owing to the flushed face and unconscious condition which occur in lioth. apoplexy and the stupor of alco holic intoxication may easily be confounded. In in- toxication, however, the alcoholic odor of the breath may be a guide, but it must be remembered thai form of alcohol is often forced upon any sick man by a kindly but injudicious bystander. The pupils are more often dilated evenly, and the patient can often be partially aroused from the condition' of stupor, al- though he may sink again into it at once. In acute alcoholism an emetic may be given, and after he has
30
jo6
NU/tS/NG
vomited freely the patient may be turned on his side and left to Sleep off the effects. A nurse must never take the responsibility of these cases upon herself, as a condition of coma not unfrcqucntly simulates so closely that of alcoholism thai even physicians of wide experience may be unable to decide at first as to the correct diagnosis. This is more particularly tnic in cases in which no history of the onset of the attack is obtainable. Many cases, which have been classified as instances of sudden death from heart disease or apoplexy, have now been shown to be due to disease of the coronary arteries of the heart.
Coma means a condition of profound insensibility, during which the functions of the brain are in abey- ance. It may be due to various local causes, such as compression upon or hemorrhage of the brain, or to the circulation of poisonous substances in the brain as in urarmia. Thus we may have a urarmic, a diabetic, a post -epileptic, an alcoholic and a narcotic coma.
Sunstroke, or insolation, as the name indicates, some- times results from prolonged exposure to the sun's rays, but heat-stroke more often comes on not from anv direct exposure, but from staying too long in a continuously high temperature. There are two forms —one in which the temperature is high, and the odier in which it is subnormal. Gises in which there is no elevation of temperature are classified under the head of "heat exhaustion."
In sunstroke, or thermic fever, the patient has an extremely high tempt rat tire, from 106* to no" F. or even higher. He is unconscious, the face is deeply flushed, and the breathing deep and labored. The first thing is to reduce the excessive tempera-
ARTIFICIAL RESPtRA TION
307
hire, which should be done in hospitals by immersing the patient at once in a cold tub-bath at from 6o° to 70° F., to be continued for fifteen to twenty minutes, while iced com|>p v ire applied to the head. If the tem- perature continues high after the patient has been removed from the rub ice packs may be employed, but the continuous tub with ice is better. Or he may be stretched on a bed covered with a long rubber sheet and freely sponged with ice-water and rubbed over with left If in a tent, tin- patient may be placed on the ground and water from a hose or pails poured over him, care being always taken to make sure that the head is kq>t cool and wet. In addition to the above treatment a method recently adopted is the sub- cutaneous or intravenous injection of normal salt so- lution, about 1000 cc. to 1500 cc. being injected at one time at a temperature of 97° F.
In heat exhaustion the SymptORU may lie quite the opposite, and resemble those seen in a condition of slunk; the temperature is subnormal, the pulse small and rapid, the extremities are cold, and consciousness may be entirely lost. Stimulants are given until the pulse improves, the patient being kept quiet and in a dark room.
Artificial respiration is resorted to when a patient has ceased to breathe, and the employment o! median ical means promises a restoration of the act of respi- ration. In asphyxia from chloroform, in narcotic poi- sonings and suffocation from gases, with the new- bom infant, and in cases of drowning, it is often necessary.
Sylvester's method is considered the best. The pa- tient is placed on his back with a pad just under the
308
NUKS/NG
shoulders to assist in the expansion of the chest-walls : the tongue must be caught with forceps and drawn out. the forceps being left on to prevent it from slip- ping back ; or after hcing drawn out it may be held in place by a dry handkerchief or strip of cloth tied to it, the end* of which are crossed at the back of the neck, brought around and fastened under the chin. The operator standi or kneels at the head and, grasping the forearms at a point about halfway between the elbow and the wrist, carries the arms steadily over the pat'ii ill's head until the hands touch behind. By thCM means the chest-cavity is expanded. After being held there for two seconds, until sufficient air has entered the lungs, the arms are carried back and pressed against the sides of the chest in order to expel the air ; after in interval of a few seconds the process is repeated. This is continued, the movements being made steadily and slowly at the rate of sixteen to the minute, corre- sponding to the number of normal respirations. Much perseverance is necessary, as we may often have to work for two hours or more before any signs of life or breathing become visible. It is to be remembered that there is always a tendency to perform the movements too rapidly.
Marshall Hall's method is to roll the patient over on
Face and make gentle pressure on the back in
order to expel the air from the lungs. In order that
it may enter them, the patient is rolled over on his
These movements are repeated at the same
rate as in Sylvester's method.
To restore a person who is apparently drowned, one must lose no time, but begin at once by removing the clothes as far as the waist. The mouth is pressed
POISONING
3°9
open, wiped out, and the back of the throat cleared of any mucus that may have collected there. The patient is next turned with his face downward, the abdomen being allowed to rest on a folded coat or shawl or over the knee of the operator, and pressure is made on both sides of the thorax, so that any water which may have entered tlie air-passages may be forced out. When this has been accomplished, the patient is again turned on his back and artificial respiration is started. In the meantime some one should have been sent for stimulants and blankets. Hot and cold water alter- nately dashed on the chest may assist in exciting the respiratory movements. As soon as possible the pa- tient should be enveloped in blankets and surrounded with hot cans, and even after he has begun to breathe fairly well he must still be watched until there is no further danger of cessation of the respiration.
Poisons, as the term is popularly understood, are substances which when taken into the body even in small quantified endanger or terminate life. They may be taken accidentally or with suicidal intent, and it is usually under such circumstances that a nurse is called upon to act with promptness in order to counteract or check the action of the poison. If a poison has been administered by accident in the presence of a nurse, she should relieve her patient, as far as possible, from anxiety or nervous shock by making any necessary statement as little alarming as possible, and by taking prompt steps to remedy the evil. A physician >hmild at once be sent for, and in the mean time, according to the nature of the poison, remedies may be administered which act either by removing the substance or by prc\cnting or counteracting the action of the poiwn.
3io
AUteS/lVG
Such remedies are termed antidotes. An antidote may act in one of three ways: mechanically, by preventing absorption or by emptying the stomach; chemically, where one substance, combining with another, pro- duces a comparatively harmless third substance; or physiologically, where the substance administered counteracts the effects of the poison upon the system. When one has to act upon general principles without knowing what the poison is, an emetic is perhaps the best thing to give first. One that can nearly always be obtained in a moment is mustard and warm water. For an adult half Bfl ounce, and for a child two drachms, of mustard to a cup of water may be given, and the draught repeated every ten or fifteen minutes until free vomiting is produced. Salt and warm water may be uwd in the same way, or vomiting may l>e produced reflcxly by tickling the pharynx with the index finger or a feather.
Tlie other common emetics ordered arc — sulphate of zinc (10 to 20 grains) in a cup of water repeated every fifteen minutes; powdered ipecacuanha (15 to 30 grs.) or fl. cxt. ipecac ( 15 to 30 mins.). or syrup of ipecac (a teaspoonful).
The washing out of the tfomadl is generally the quickest and best thing to do if the mucous mem- branea have not been too much injured by the action of the poison.
Poisons may be divided, according to their action, into corrosives, irritants, narcotics, and narcotico-irri- tants.
A corrosive poison is one that is likely to eat or burn throupb organic tissue instantly, while an irritant |Miison is one Which acts more slowl\ upon the tissues,
I
POISONING
3'»
producing inflammation which may result later in sup- puration and perforation.
For these violent poisons the antidote should be one which will act chemically upon the poison, cither rendering it harmless or at least reducing the intensity of its action. An emetic i--. ;is ;i rule, not indicated, the action of sulphuric acid, for instance, being usually so rapid that the tissues would be injured long before an emetic could be given, so that the latter would only add to the irritation. The stomach-pump should not be used, as its introduction may assist in the destruc- tion of the mucous m rnbrane and produce perforation. Demulcent drinks (mucilage) may be given, and if possible some chemical antidote.
In the after-care of patients suffering from poisoning from irritants, great care should Ik- taken with regard to the diet; only the »<>tt. BOO -irritating foods should be given, such as finely-strained gruels, milk-porridge, egg albumen, etc.
In narcotic ur narcotico-irritant poisoning the action is systemic, and the antidote may be a combination of all three forms.
Below we have tabulated some of the more import- ant poisons, together with the treatment to be followed when they have bun taken into the stomach:
Cormivt Atjwu -•
The Ai Uh
Aretic. Citric.
Hydrochloric. Nitric.
Oxalir Sulphuric.
Carbolic acid.
Immtdiatt 7**atmrnt.
Give magnesia mixed with milk Of water, chall. powtttj «>r an • II. ill. such at soda, diluted fol- lowed br white of c*ii and mucilaginous drink-
Whiskey or tome other form oi al- cohol, I ii-om or dauber's salts. • i. inllk or lime water. No oil, •< il udi absorption.
|
— LB ' |
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NURSING |
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For any alkali (ire a mil.l acid. |
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Ammonia. |
such as vinegar or lemon-juice. |
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ClUIIII potaili or MdeV Potassium nitrate laallpcirel. I'alnum .:.• |
1 ', carbolic acid in water or sour |
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Us Alk.lln |
n.Ur V alia, auch aa sweet oil Of castor oil . (he alk alica |
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form ernuliiona. Bland drinks, albumen, ric. |
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|
Irtu |
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Tartar «mccic. |
Produce rmnii. Give at antidote |
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M lot ol arrimooy. |
tannic acid or very >tron« trj |
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Syrup ol squilla. |
Follow with demulcent dnnki |
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(lire an cmelic ol muoan! jnd water. The antidote it Ik* Iit drated sesiiuiotideof Iron, made |
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Fowler's solution. |
(reality by adding a sumcirnt |
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quantity ol aqua ammonia or of |
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Arsenic |
Pxri» areen. |
a solution of carbonate of aoda |
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Koaat on R m |
tu tlic tincture ol iron to form a |
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Artcniout acid. |
heavy rrd precipitate. Strain and wash the precipitate and it in milk or water, and five |
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freely and frequent!). |
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r BtcMarldt ••( mti- |
Albumen (white of eggl it a chem- |
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ran (corro-ive |
ical antidote, one egg to 4 it. ol |
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Merciirydiy drsrgyruml |
mbUmit)i |
themerrur* afOJl mayalsobe |
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1 |
given and then flour pa.ir |
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lllue mass. |
Vomiting it to tir induced altrr the antidote ha» been given. Starch or flour, mixed into a paate |
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Iodine . . . |
Tincture of iodine. lire. 1 |
with water, should be given, fol- lowed later by an emetic. |
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Iran |
Syrup. .1 |hi iM.lirlf. |
Antidote, magnesia, Plenty ol |
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M |
water to drink, Produce cm> |
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the tubtulphatc. [ 1 |
Antidote, aulphate ol aoda or of |
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Lead ■ . . . < |
AcrUte of leml |
magnesium (Fpaom Mil* |
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1 umar of Icjili |
'* h i r r nt egg or milk I'secmel- ics or ttomoch pump |
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Matches. |
r, mil the atomach in ' |
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. i.nie ol sine |
cases Aa an emetic, sulphate ol |
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Pkotpborai |
IMI. |
copper anawera vicll (hi must |
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vavfooi vinitt <>f |
never be given, aa it dissolves |
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kypuphotphiirt. |
phosphorus and battens itt ah. sot|" |
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CtM< |
«St 1 'iMiit'nnjtinc gat) J 1 |
h air. Anihcial retpiratloii. Stimulant*. • |
ro/so.\'fNC
3*3
Nartctia end AfararfinT-rrrrrun/i . Fluid extract. Tincture.
Aconite
Meohol
«MU ...
■{
(Brandy. |
Whi.key. Wine., etc. I
)
Tincture. Belladonna . { Fluid extract.
Atropine (alkaloid!
Digital!.
Chloral .
Ilrotcyamua
t hlorofurm
I .."lure. Fluid extract.
Chloral hydrate. Croton chloral.
Tincture. Extract
Sulphate of hyencya- mlne.
l-'.mctir, or .tomach-pump, cxtrr- nal and internal atimulation; at- repln ur digliall..
Stomach-tube, colli application* tu head, heat to cxtrcmttict. inhala lion ol ammonia (cautioualy).
Etnetira or atomach tube, tannic acid, and morphin Artificial reapiration. heat. Rectal loiec tiona o( .trong coffee.
Kmelica. tannic acid In large quantities Hot external appll cationa.
Wath out the atomach with tea or
coffee. Alcoholic stimulant.,
:.r.in. Artificial rcxpita-
HM. External heal, muitard
lHHHH. muaurd footbath, etc.
Same treatment a> for helladnnnx- pm.omng. Freah air. Cold-water •ffuainn.
Artificial rcupiratioil. Stimulant*. Stryclinin h, p.")crmtcally. . ..iiiiter-lrritanH.
Prompt emetic». Tannic acid. Ar- tificial r expiration.
Emetic Wa.h out the .tomech. Tannic add or tincture ol iodine. Morphin or chloral lor the con- vulaicnt.
Emetlei. «uch aa tulphate of line or muatard. Waah out the atorn- ach fllllllMllj »ilh water or a weak lolution of potatiium per- manganata. Cold-water aflu- alona. Strom Mack coffee by mouth and rectum. Artiliclal respiration. Keep the patient awake.
Poisoning may also follow the um of certain Idndl of mushrooms, tainted meats, fish, cheese, milk, and ice-cream. In such cases prompt emetics, followed by purgatives and stimulation, internally and externally, should be employed.
Except in the case of mushrooms the poisonous properties of these substances arc often the result of bacterial growth.
Nicotine . . { Alkaloid of tobacco, y
Nux vomica
I Ipnui.
Tincture. Fluid etiracl
Strychnia.
Laudanum. Paregoric. McMunn'x fibril Morphin (alkaloid).
3'4
.S'UfSfNG
For medical nursing bat few appliances are ne in proportion to those required in surgery ; still, there arc certain things which are necessary and which should be kept on hand ready for use.
The same convenience* for applying beat externally, such a? hot cans and bags, with their canton-flannel covers, arc required. Pneumonia cotton-jackets, lamb's - ool, flannels with oiled-silk covers for stupes, should I z ?cept made up, since they may be needed «it «iny moment.
An auscultation towel should be a yard square, and made r-f cambric or Victoria lawn or of some other thin white material ; it is used by the physician during the examination of the heart or lungs when he wishes to listen with his ear directly against the patient's body. It should be thrown by the nurse over the patient's face and chest. When laundered no starch is nsed, as it must be soft and noiseless.
Cupping-glasses, an aspirator, one or more tubes, and catheters should be included among the | manent ward supplies.
The aspirator is an instrument used to withdraw serous or other fluids from the pleural or abdominal cavity j by means of it suction is possible without the introduction of air.
In preparing for aspiration the needle should be sterilized in :'■ way as that of a hypodermic
syringe, and the part of the body where the needle is to be introduced washed off first with soap and water, then with bichloride solution, and afterwards with al- cohol. Besides these, there must be a basin of carbolic- acid solution, towels and sponges, a hypodermic sy- ringe, a solution of cocaine, stimulants, and, if the
LAVAGE
3*5
amount to be drawn off is very large, an extra re- ceiving vessel should be ready. A small dressing of absorbent cotton and cclloidin or strapping will be necessary for application after the operation.
If a patient is to be tapped for ascites, a rubber sheet and an abdominal bandage will also be needed.
For venesection the same antiseptic precautions are taken as for aspiration, and in addition to the things mentioned above, artery forceps, dressing forceps, a scalpel, scissors, needles, and ligatures (all sterilized) must be ready. The dressings necessary for a minor operation will also be required.
In some diseases lavage of the stomach is ordered: a long rubber stomach-tube is used and the stomach is washed out with lukewarm sterilized water or a warm boric-acid solution. For this procedure there should be in readiness a rubber sheet, soft bath towels, a good-sized basin, a gallon of sterilized water at about ioo° P., and a two-quart pitcher. The patient may sit in a chair or, if in bed, he may be supported by a head rest. The head should be inclined BUghtfy hut not too far backward. The tube is inserted as far as the back of the pharynx, and, the patient being told to swallow, is passed down the oesoph- agus, its extremity having been previously dipped in water or oil. The mouth of the tube is slightly < h vated and half a pint of the irrigating fluid is poured gently in through a funnel. The outer end of the tube is to be lowered before all the fluid has run in In the stomach, and in this way the gastric contents may be siphoned off into a basin. The process is repeated until the washings become clear. After the stomach has been thoroughly cleansed, nourish
3*6
XURSMG
ing food is sometimes introduced through the stomach- tube. This latter procedure is known as gavagt.
On medical morning rounds the head nurse should always have with her the book containing the night report, an auscultation towel, a tongue-depressor, a measuring-tape and a thermometer. She should an- ticipate as far as possible anything that may be asked for and be prepared to answer questions regarding any of the patients under her charge.
CHAPTER XVIII.
SUTCKAl N'URSJNC— ASEPTIC AND ANTISEPTlr SOMBT<— THE
HkALlMO ok Woi.'nds. — Inflammation. — COKHJI MlOHS — Surgical Dressings. — Preparation of Path Operations (Capital and Minor)— Care of Patients Arm Operation— Nlksinc in Slrgical Disea5.es.
In order that a nurse may appreciate the technique of modern surgery and the importance of carrying it out in its minutest details, she must try to understand iln underlying principles which tttVC bttfl established hy scientific research in the field of hacteriology.
It has already been stated that decomposition or putrefactive changes cannot occur in the albuminoid tissues of the human body without the presence of some form of microscopic life, and that the organisms that produce such changes in the tissues arc of dif- ferent varieties, the most important being cocci and bacilli. The micrococcus is a spherical, the bacillus a rod-like, organism, tod there are many varieties of each, which can be distinguished by differences in shape, motility, growth on culture media, and the pathogenic effects resulting from their introduction into animals. In abscesses the organism most fre- quently found is a coccus, groups of which are seen arranged in the form of little grape-like bunches, and which produce a bright-yellow color when grown on urface of a boiled potato. Hence it has been named the staphylococcus pyogenes aureus (golden
pus-producing coccus in grape-like clusters).
in
tfVKS/XC
For acute septicemias, which cause death in a few days, usually without pus- formation, a coccus is also often responsible, but this kind, instead of growing in grape-like clusters, generally forms chains, and has been named Streptococcus pyogenes (pus-producing chain coccus).
Wound-infection cannot occur without the presence of some organism, and wounds, whether operative or accidental, afford favorable conditions for the reception and development of germs, for in them micro-organ- ism find nourishment, moisture, and a suitable tempera- ture, the three essentials necessary for their growth. The ways by which they may enter arc numerous. Into an accidental wound, germs may be introduced by the instrument causing it, by the clothing, or by dirt which has been allowed to enter before the surgeon sees the case. In i cases, if infection fakes place, the
organisms have been introduced into the wound bji the surgeon, '>;. liis assistant, or by the nurse through some fatili in technique I thus the instruments, dressings or hands may not have been completely sterile. There is one exception, however, to this rule, since it is Im- possible to thoroughly disinfect the skin, and wound- infection may arise from organisms which have their habitat there.
Although, as has been proven, chemical agents are capable of causing pus-formation, yet, clinically, they never do so. Chemical antiseptics, however, if used in strong solution, arc very irritating, and may injure or destroy the tissues, lessening their normal resist- ance, and forming a favnralile medium for the growth of germs Wounds that have become the *<-at of rial growth are called infected wounds, and arc
jsr.rsts
3*9
in a condition of sepsis, poison.- being produced wliicli are carried Into the circulation by the lymphatics and blood-vessels, causing an inflammation in the wound and septic fever — a condition usually indicated first by a rise of temperature and an increased pulse-rate. Oc- casionally not only the poison enters, but germs them- selves get into the blood-current ; then we have to do with a general blood-infection, and not simply with a localized wound-invasion with secondary blood-intoxi- cation.
Modern surgery aims at the prevention of wound- infection by bacteria, and attempts the destruction or Inhibition of the growth of germs already present. Two expressions commonly used with reference to the treat- ment of wounds arc asepsis and antisepsis. By an aseptic wound we mean a clean wound, free from germs, while antisepsis refers to the measures em- ployed to destroy organisms which may be present either in the wound or on the skin, hands, and instru- ments, all of which must be sterilized and made free from germs before coming in contact with any, but more especially with a clean wound. Hence the most minute precautions must necessarily be taken by both surpcons and nurses in preparing themselves or any- thing that will conn- in s-ontai't with a wound during an operation, or at subsequent dressings.
The term "clean" and "surgically clean" have then. two widely different meanings, since "surgical cleanli- ness" should signify a complete absence of germs. To secure this aseptic condition, both chemical and natural agents are depended upon, and with the patient the first steps arc taken some hours previous to the opera- tion by rendering the skin of the body over and around
J20
NURSING
the scat of the operation as clean as possible. Pncti cally, "surgical cleanliness" of the skin in the strictest sense of the term, is at present impossible, for in spite of all known methods of disinfection, in the glands of the skin certain bacterial forms are constantly present.
But the healing of wounds depends first upon the kind of wound, and secondly upon its aseptic condi- tion. A wound may be defined as a solution of con- tinuity of the soft parts. Wounds are classified as —
Incised, such as are made with a lharp instrument ;
Contused, such as arc matie with a blunt instrument ;
Lacerated, when the tissues are torn and ragged :
Punctured, when made by a pointed instrument — e. g. stab wounds.
Wounds are also spoken of as infected or non-in- fected, according as they do or do not contain path- ogenic or disease-producing organisms in sufficient numbers to disturb the process of healing.
With a wound there may be pain, gaping of the edges, and bleeding. Pain varies in different people and in different parts of the body.
A lacerated wound beneath the skin, where the sur- face of the latter is not broken, is called a contusion or bruise. Contusions are caused by direct violence. The Symptoms arc discoloration or ecchymosis, indicating U extravasation of blood. In a contusion or bruise the object in treatment is to prevent further effusion of the blood, to control the pain and inflammation, to preserve the vitality of the tissues and to promote absorption. Heat applied at some distance from the bruise relaxes the surrounding vessels and promotes rption. Cold has the opposite effect ; it contracts the blood-vessels and prevents absorption.
■t
. ; SEJV/S
321
Until recently it was thought that the healing pro- cess in an incised wound differed from the repair that went on where a cavity had to be filled up by means of granulations, and the healing of a clean incised wound was called healing by first intention, or primary union; where the process was brought about by the filling up of a cavity, this was called healing by sec- ond intention, or secondary union; and when two granulating surfaces came together, the wound was classified under those which healed by third intention. It is now taught that the process of repair that goes on in wounds under any circumstances is precis.lv the same, the only difference being that in an incised wound, little injury having been done, only slight reparative processes are necessary, while, where there arc large cavities which must be filled up by granula- tion-tissue, much more extensive regenerative changes arc needed.
The healing of wounds should therefore be divided into only two divisions — aseptic -wounds, in which Un- healing is not retarded by bacterial poison and growth, and infected wounds, where there is delayed healing owing to the action of bacteria. In wounds that heal by first intention, as in a clean incised wound, no granulations are visible. The two edges are kept in close apposition, the blood and lymph on the cut sur- EtCM |oil] them together, the healing | takes
place rapidly, and there is very little opportunity for the entrance of germs.
nindfl which heal by granulation, or by second
intention, are much more difficult to keep quite free
from infection, although every care should be taken
to do so. Healthy granulations are small red elcva-
zx
m /■
lion* which spring from the fixed cells of ihe con- nective tissue. They gradually till up a wound, start- ing from the tides and the bottom. Granulations may grow too rapidly and increase beyond the desired point, in which case they must be reduced and kept in check by the application of some astringent : nitrate of silver, either in pencil form or in solution, is the one most frequently used. On the other hand, the granulations may l>e pale and flabby and ini-d stimulating: balsam of Peru is then most often applied. Where there arc very large granulating surfaces, as after large burns, skin-grafting is resorted to to hasten the healing. The entire surface is covered with thin layers of skin as l;ir^<' as can o mvinirntlv Ik- shaved from some Other portion of the patient's body, the leg. thigh, or arm being Rencrally chosen. To prepare skin for grafting purposes, the same antiseptic precautions must be rig- idly carried out as in preparing a patient for operation. When all is ready the skin is shaved off with a large sized knife with a very keen edge ; the graft is at once iVrrcd to the wound, and spread over it. unless it has become doubled up, when it is first floated out in normal salt solution. Strips of rubber tissue should be laid in salt solution in readiness to cover the wound before applying the pads of gauze. The tissue prevents any disturbance <>f tin- m-wlv-formed -.kin surface, and the granulations are not torn when the dressing is removed.
A cavity formed by the removal of a quantity of tis- sue may be allowed to fill with blood, which forms a clot, and this blood-clot gradually becomes organized, the fibrin forming a delicate scaffolding upon which new blood-vessels and granulations find support. This
INFI.AMUATIOX
3*3
method of filling up cavities and dead spaces is some- times made use of by surgeons.
Where granulating wouutrs have a tendency to heal over from the top they may be kept open by means of drains or gauze packing. Sterilized ruhl>er tubing of various sizes and strips of plain or iodoformized gauze, bismuth gauze or rubber tissue, are kept" for this purpose. The plain or bismuth gauze is consult red more suitable for most granulating cavities.
Inflammation is sometimes found in connection with wounds, and is a condition of great Importance. All diseases the names of which terminate in "itis" arc inflammatory in character. Inflammation comprises those changes in the tissues which result from the action of certain irritants. The causes are —
i. Mechanical — blows from different sources;
2. Chemical — various corrosive poisons;
3. Physical — heat, cold, or electricity ;
4. Infectious inflammation (caused by micro-organ-
isms).
The phenomena of inflammation arc dilatation of the blood-vessels, an increased flow of blood to the part, the appearance in the tissues of leucocytes or white blood-COrpuSCles and of red blood-cells which have passed through the walls of the vessels, and the exu il .lion of blood-plasma.
An inflammation is said to be fibrinous, serous, or purulent according to the nature of the exudate. The symptoms are he.-il, redness, swelling, pain, tenderness and disturbance of function of the inflamed Dart
The object in treatment is to remove the cause, or, if ibis ciiiiiot be done, to protect the tis-sucs as far as possible from further irritation. If the inflammation
J*4
NUMSING
subsides, resolution has taken place, but if the inflam- mation continues, the termination is usually in abscess. suppuration Or gangrene. Inflammation in connection with wounds is most often due to infection, and if it results in suppuration, the abscess should be opened up freely ami allowed to drain thoroughly. With the various kinds of wounds — the results of accident or operation — a nurse will become familiar during the course of her training in the surgical wards and operat- ing-rooms, but to become familiarized with | wounds and their treatment, the surgical dispensary training is the most desirable and should precede the ward and operating-room experience. In addition, it is most important that a nurse should be informed of the various complications that may develop in connection with wounds and after operations. Theso arc various forms of blood-poisoning, septicemia, i nia, saprarmia, erysipelas and tetanus.
Erysipelas is an acute highly infectious disease, the result of the invasion of a virulent micro-organism (Streptococcus). Tt usually appear* in from three to seven days after exposure, and is ushered in by a chill and elevation of temperature. If it be a wound that has become infected — and the majority of the cases of erysipelas arise in this way — a characteristic bright-red flush appears about it. If there is no percc tible ahrasion the flush first appears on the nose and cheeks. The face becomes badly swollen, the skin smooth and tense, and small blisters may appear. A lint mask may be applied to the face, and kept mois with a disinfectant. The patient should be isolated once and the usual precautions taken.
The terms septicaemia, pyaemia, and sapraemia hav
n.KMlA
3*5
come to have an altogether different significance since our knowledge of the infectious processes has bei extended. In both septicaemia and pyemia there is a general blood-infection with pus-producing bacteria, resulting usually from the infection of an open wound, accidental or operative. In an acute septicaemia the cocci multiply rapidly in the blood, and arc very viru- lent, causing death sometimes in twenty-four or forty- eight hours through a direct poisonous effect upon the whole system. The symptoms are, as a rule, a sudden chill, accompanied by considerable elevation of tem- perature, a rapid compressible pulse, and vomiting.
In f>yacmia, on the other hand, either the bacteria arc less virulent or the patient's tissues are more re- sistant, and the disease, lasting longer than acute septicemia, results in the formation of multiple ab- scesses all over the body, particularly in the joints and larger organs. The fever runs the so-called "choppy" course which is seen on the charts of pus cases of all kinds, the temperature being perhaps normal in the morning, and going up to 103° or 104* F. at night. There will be chills, followed by profuse sweating: the patient becomes rapidly emaciated, and develops a hectic flush on his cheeks ; the pulse becomes small and very frequent, and finally death occurs from exhaustion. There is no sharp dividing-line between septiexmia and pyrcmia, and cases apparently half- way between the two conditions just described have hern called cases of septicopyemia,
Sapraemia is an entirely different process. Here the pus-formation is altogether local, and the bacteria do not get into the blood and go all over the body. Severe symptoms, and even death, may nevertheless
A'UA'S/JVG
occur from absorption of the toxic chemical products nun i tin local abscess or slough.
Tetanus, popularly known as lockjaw, and formerly supposed to be purely nervous in its origin, has been lun'.tn to be caused by a peculiar kind of l>acilhis. This species is found most often in garden earth, manure, or putrefying fluids, the poison being con- veyed by the earth or dirt that is carried into a wound cither at the time of its occurrence, or afterward where ii bai not been properly protected. The affection be- gins with stiffness in the neck, and a tightness about the jaws which increases until finally there is a tonic contraction of the muscles of mastication, which is called lockjaw: the stiffness extends gradually over the body These spasms are severe and painful; the patient lies perfectly stiff and rigid, or may be drawn up so that he rests upon his head and his heels. The greatest quiet should be observed, as noise or irrita- tion may excite more convulsions ; the room should be darkened and no one allowed to enter but the physician and nurse. The.se cases are usually fatal. If nourish- ment cannot be taken by the mouth, an attempt should be made to give it by means of a tube, through the mouth or nose or by rectum.
The tetanus antitoxin. The results obtained from administration of this substance in the disea e itsdf have not been up to the present time very encouraging. Nevertheless, its use as a prophylactic is indicated from the fact that it has often been injected into horses occupying infected stables and has apparently pped the spread of the disease.
For the regular surgical dressings (or, in hospital parlance for "surgical rounds") one nurse should be.
SURGICAL ROUNDS
r-7
. .penally appointed, for a certain length of time, to make the necessary preparations, and before the hour for rounds the hcail nurse should see for herself that nothing has been forgotten. There should never be anything wanting in the form of a dressing or ap- pliance that may be asked for by the surgeon ; any omission shows either lack of management or care- lessness.
Dressing-carriages or trays should be made with regard to cleanliness as well as to convenience. The kind that fulfills these requirements is made almost entirely of glass with a light iron frame. If dressings are made from bed to bed, a portable washstand is also convenient, as the surgeons wash their hands before each dressing. The articles that should always be ready for surgical rounds in a ward are —
The dressing-carriage, fully equipped with solutions, bandages, and other appliances.
A portable washstand, with plenty of hot and cold water, soap, and brushes for scrubbing the hands.
White-rubber sheets, from six to twelve in number.
A covered granite-iron pail for soiled dressings.
One dozen granite-iron basins.
Irrigation-bags.
Sterilized dressings and instruments.
Besides the head nurse there should be two assistant nurses, one to go ahead and prepare the next patient, the second stationed near and ready to wait upon the head nurse, whose duty it is to sec that the bed and patient are prepared for the dressing and that the surgeon i9 promptly supplied with whatever he re- quires. It does not do for a nurse to wait to be told what the surgeon will use next ; she must train her-
3*8
KVKSIHG
self to anticipate his wants and have everything ir readiness. Everything should be done not in a hmrit or excited manner, but coolly and collectedly. Talk- ing at rounds should be limited to necessary ques- tions and answers, and a quiet dignity observed in accordance with the seriousness of the work engaged in. To do good work a nurse should give it her un- divided attention, and laughing or chatting before a patient, who perhaps is in pain, is quite nut of place.
Where practicable it is better to do all dressings in a room of medium size adjoining the ward, since the appliances can be kept more easily in a compact and surgically clean condition than when they must be car- ried about. Moreover, nun-h time is saved, other pa- tients will not be disturbed by the sufferings of the one who is being dressed, and the ward can be kept free from the contamination of soiled dressings and from much disorder. Patients can be transferred from tin ir beds to a wheeled stretcher and rolled into the dressing- room, or else, if the bed is on casters, it may be wheeled to the dressing-room door, and the patient lifted directly from his bed to the dressing-table.
Preliminary preparation of a patient. Before carry- ing out any operative procedures which are not urgent it is advisable that some days or even weeks should lie devoted to the building up of the geiu ral strength, or in other words to the increasing of the patient's chances of recovery by adding to her powers of resistance. Such a period requires the most cheerful surroundings possible; a light wholesome diet; plenty of water to drink, an abundance of fresh air and sunshine with massage and rest in bed. A bright, kind, and thought- ful nurse can do much towards improving the patient's
L
AN OPEKATIOX
3*9
condition. The patient should not be allowed to be disturbed by seeing many visitors. During this time a specimen of the urine should be sent to the labora- tory daily for an examination.
The immediate preparation of a patient should be begun from fifteen to eighteen hours before the time appointed for the operation. A general bath should first be given with hot water and soap. Next, not only the part where the incision is to be made is shaved, but also a large area around it, which perhaps will be touched by the operator's hand. The skin should be left smooth and quite free from hairs, and then scrubbed with green soap ( a soft potash soap very strong) ; a green-soap dressing should then be ap- plied and left on for an hour and a quarter. In rectal cases if the tissues are broken down the green soap is omitted; the raw area is covered with rubber tissue and sealed over. The preparation of the surrounding parts can then be proceeded with. If the surface be thick and hard, like that over the patella, it should again be well scrubbed and the green soap reapplied for another hour, after which it is to be sponged off with 1 13000 bichloride solution and enveloped in a sterilized dressing securely put on. This may be saturated with a 1 13000 bichloride solution or a 1:80 carbolic-acid solution, about three hours before the operation. This form of preparation within the past year has been done away with by some surgeons who require no preparation of the patienl until placed on the operating table, but until this method has been generally adopted the above procedure must be under- stood by the nurse. A purgative should be given for two successive nights before the day of the operation
HURS/NG
or frequently enough to have the intestinal tract well emptied ud not distended by flatus. To ensure a thorough evacuation a simple enema is given in the morning. Three hours before the operation is per- formed the enema should be entirely expelled, par- ticularly in plastic operations on the perinatum, and unless a stimulant or a cup of hot becf-tea is ordered early in the morning, nothing should be given by mouth aftir midnight. The urine should be either voided or drawn off by catheter just before the patient is sent to the operating-room. For vaginal operations a douche should also be given ; the patient should be attired in a fresh short night-gown, stockings, warm wrapper and flannel combinations. If the nature of the operation will permit, a flannel undervest .should always be worn or a loose flannel jacket. A woman's hair should always be well brushed and braided ; all jewelry, and any artificial teeth should lie removed. The same preparations apply for a minor operation if there is time, but the purgative may be omitted unless an anxsthctic is to be given. It is undoubtedly pleas- antcr for the patient if the anarsthetic can be adminis- tered while she is in bed. Generally, however, this i* impossible, and she is conveyed to a room especially set aside for the giving of the anxsthctic. The room is generally close to the operating room, as the operator can in this way he near by in case any difficulty arises as a consequence of the anaesthetic. In a hospital the patient's chart and history are sent to the operating room with her. It is necessary to do many minor operations at very short notice, and in these cases the preparation should consist in scrubbing the surface with green soap and hot pcrmanganate-of-potash and
AS OPE RATIOS
33*
oxolic-acid solutions; finally, it is sponged with ether and alcohol and covered with a dressing saturated in bichloride solution (1:1000,) and the patient is ready for the operation.
In general surgery the after-care of the patient after the first twenty-four hours is, as a rule, very simple, unless complications arise, and good nursing will do much toward a rapid restoration to health. The prep- aration of the bed for such patients has been men- tioned before. Immediately after the operation is ov>i . the patient is placed in bed and ;i nurse detailed to remain beside her until the effects of the anaesthetic have worn away. If there be much nausea, water should be given sparingly at first, as it only aggravates the trouble : sips of hot soda-water are better. A con- dition bordering on collapse or a complete prostration of the vital forces may follow a severe operation, tin pulse being very small and feeble, the face and lips pale, and the body covered with a cold perspiration. Such a patient should be wrapped in warm blankets, with plenty of hot-water bags about her, the body rubbed with alcohol, and a stimulant, cither strychnin, atropin, morphin, whiskey or brandy, must be at hand ready to be given if ordered. After major operations hemorrhage should be watched for during the first twenty-four or forty-eight hours: indeed, the pos- sibility of such an occurrence should be borne in mind until the wounds have healed perfectly, as secondary haemorrhage may occur several day] iftW the opera- tion. Perfect quiet should be maintained, as any un- due noise adds to any nervousness that may be present. As soon as she become-, contdoui and the effects of the anesthetic arc wearing off, everything possible
3J2
NURSING
should he done to add to the patient's comfort. An ice-bag may be ordered to be applied to the head. Frequent gentle sponging of the face, hands and ex- tremities with cool water and alcohol are Sometimes very soothing. Rubbing the back and limbs with alcohol and placing pads under the back and knees will case the patient ; she should be well bathed night ami morning and watched carefully in order that bed-sores may be prevented. The nourishment ordered at first is usually in the form of fluids or a liidit diet — milk. eggs, and broths — but, as a rule, full diet is allowed very soon after the operation. The pulse and tempera- ture are t< > lie recorded twice dails, unless the symp- toms require that this should be done more frequently. As soon as ever her condition justifies Ul in doing so, the patient should be lifted nut of bed into an invalid chair, or carried out of doors into the fresh air and sunshine, as it is important in every way to keep up the general good condition of the system while the process of repair or healing is taking place. Unless a serious rise of temperature necessitates an early change, a first dressing is usually kept on for a week or ten days, or even for a fortnight, according to the nature of the operation.
After a surgical operation of any kind the chief com- plications that may occur are shock, haemorrhage, sepsis, obstruction of the bowels and suppression of the urine. The S) tnptoms to be looked for arc an eleva- tion of the temperature, a quickened pulse-rate ; (lis tcntion and pain in the abdomen ; an anxious expres- sion of the countenance; nausea and frequent vomit- ing and inability to expel flatus. If vomiting is present it is better to discontinue all feeding by the
n.i.MOh-h'iioms
333
mouth until il ceases, For distention a rectal tube is sometimes inserted for 5 or 10 njinutcs at a time. The bowels arc generally ordered to be opened on the day after the operation. The character of the pulse and temperature will give the best indication as to the patient's condition.
The following are some of the more common surgi- cal diseases that require careful nursing.
Ulcers or open sores occur internally and externally : tlu-v are of many kinds, arise from different causes and present various appearances. As a nurse is some- times detailed to ilics.s ;m ulcer she should be familiar with the various changes it may undergo in order that she may know whether it is healing over or not.
In a healthy condition the granulations are of a bright red color and the surrounding skin has a slight- ly bluish tinge. If the ulcer is not doing well the edges look inflamed, a foul discharge is secreted ; the granu- lations are swollen and sometimes a slough is present.
An abscess is an accumulation of pus in any part of the body. External abSMSMS are often left to rupture spontaneously, but in many instances, especial- ly when the contents would escape into the peritoneal cavity, operative interference is the only safe pro- cedure.
Haemorrhoids, or piles, are due to a dilated condi- tion of the veins of the lower part of the rectum. They are frequently met with in patients suffering from constipation, which causes undue pressure upon the ha-morrhoida! veins. When inflamed they arc very painful, and may give rise to tenesmus. In the milder case* palliative, local treatment is often efficacious, but when the condition is sufficiently aggravated to render
334
NUKS/XG
the patient's life a burden removal by surgical proce- dures Im-i'duk'.s necessary, i o prepare a patient for such an operation laxatives arc ordered for two days, and i 0 the morning of the operation the field of operation is cleaned in the usual manner, a T bandage being employed to hold the dressing in place. After the operation every effort must be made to keep the parts free from infection. A solution of bichloride of mer- cury or carbolic acid should never be applied to a hemorrhoidal surface, as severe poisoning from ab sorption has often been mcl with.
By tracheotomy we understand an operation in which the trachea is opened and a tube i* inserted ii- order that the patient may be enabled to breathe. It is usually an emergency operation, especially in cases of cedema of the glottis or tumors of the larynx, when the mucous membrane becomes so swollen by the effusion that the patient is in danger of dying from closure of the air passages. The same danger is present in diphtheria when the membrane has extended into the larynx and trachea. Tracheotomy is also em- ployed at times in other operations on the throat, the anaesthetic being inhaled through gauze placed in a funnel attached to the tube. The apparatus consists of a tube within a tube made of silver. The outer tube is held securely in place by means of two pieces of tape which arc passed through the holes in the tube and then tied together round the neck. The inner fits into the outer tube and projects for a short distance beyond the external end. The after care consists in the man- agement of the tube, feeding and good general nurs- ing. Vigilant attention to the condition of the inner tube is necessary, as the mucus and membranous de-
INTUBATION
335
posit are likely to fill it up and thus cut off the air supply. At first the tube may have to be taken out about every twenty minutes, or more frequently if there are signs of obstruction of the lumen. After being removed it is dropped into a basin containing a warm saturated solution of boric acid and thoroughly cleaned with a small brush ; after which it is replaced. In milder cases, however, the mucus can be cleaned out, while the tube is in position, with an ordinary wing feather, which, of course, must have been pre- viously sterilized. Care should be taken that the Cleansing process is not overdone. The surgeon usual- ly removes and cleanses the outer tube every 24 hours. The temjxrrature of the room should be kept at ~0D F. The air breathed by the patient should be kept moist, the steam from a kettle of boiling water being allowed to come in contact with the tube. Good ventilation is necessary, but the patient should be well protected from draughts. Nourishment should be given regu- larly. At first, especially in the case of a child, it may be necessary to give liquids through a tube, passed down the throat through the nostril, since tin pati.-nt will often refuse to take them by mouth, on account of the great pain associated with swallowing. In cases of diphtheria the nurse must be careful to keep her face away from the tube as much as possible when giving it the necessary attention.
Intubation has largely superseded tracheotomy for all cases of acute laryngeal obstruction, especially in cases of diphtheria. Much practice is required to perform it properly. One of the main points is that the patient should be held in a proper position, and in thu respect the nurse can render the operator efficient
ttu/tsn/G
service. A sheet is wrapped round the child's body in such a way as to render the amis immovable. The nurse then take* the patient on her knee, holding its back firmly pressed against her own body. The head is held slightly inclined backward, both for in- sulation and extubation. Casselbury's method of feeding intubated patients is as follows: Lay the child upon its back across the nurse's lap. Extend its head backwards and downwards and feed from a spoon or nursing-bottle. In the act of swallowing, Suid may be forced into the tube, gravity will then carry it out again away from the larynx — the child being still able to swallow — upward. Semi-solids can some- times be taken more readily than fluids.
A fistula may be defined as a suppurating tube-like passage in the body. Thus by a vesico-vaginal fistula we mean an artificial opening connecting the bladder and the vagina. In these cases some of the urine escapes from the bladder into the vagina. A rectal fistula frequently follows an abscess which has formed in the rectum near the anus. It may communicate with the vagina (in which case we have a recto- vaginal fistula) or with the don surface. A blind fistula has an opening at only one end. In dealing with this last the tract may be opened up freely and the cavity packed with gauze, the wound being then allowed to heal up by granulation. Another method consists in 'lissecting out the walls of tin- fistulous tract and bringing the raw edges together by means of stitches.
A hernia is a tumor formed by the protrusion of the contents of a cavity through its wall. Thus we may have a protrusion of a portion of the bowel, or omen- tum, through the inguinal or femoral ring or through
HERNIA
3.37
an opening at the umbilicus — the varieties of hcrnix being respectively inguinal, femoral, and umbilical. In most cases an inguinal hernia U reducible, — that is the bowel can be returned to the abdominal cavity by manipulation, after which it can often be prevented from coming out by means of a truss. Sometimes the mere act of lying down will allow the hernia to return to the abdominal cavity. An umbilical hernia is not uncommon in women, after child-birth, and in infants. For the former, unless it is very pronounced, usually nothing is done as it gradually disappears of itself, as soon as the abdominal walls regain their normal firm- ness. A firm pad and binder arc sometimes used to keep the protrusion back until the opening becomes smaller.
When the protruding mass, owing to a constriction at the opening, cannot be returned to the abdominal cavity we have what is known as a strangulated or incarcerated hernia. This is generally a very danger- ous condition, for unless relief is soon secured obstruc- tion of the bowel and gangrene may occur. The symptoms of strangulation are (l) a tumor in the neighborhood of the ring, which, however, is some- times so small as to be scarcely noticeable, (2) in- tense pain over the region (3) continuous vomiting with retching, (4) constipation with flatus in the bowel which can not be expelled. When such a condi- tion is met with until a physician takes charge of the case no food and not even water should be allowed, al- though for the relief of the thirst and nausea the mouth may lie rinsed out with hot water. An enema should not be given. The patient should be kept in the recumbent position and with the hips elevated.
a*
tWKSI&C
\w loe tui: Over the swelling may relax the con-
ii, ml) i<i allow the return of the hernia.
UMd .nul if gentle manipulations fail to
|ffft| ibwU a reduction an aiuesthetic is given
ili. neoomry operation is performed. Op-
11 hernia arc usually curative, especially
'ii DO exists. A hernia of moderate
«l#»> gin griK-rally IW ROpt op by wearing a well-fitting IfttM, Imi there is always more or less danger of in- , itkm.
/«/., Hon i* due to the slipping of a part of
Into the portion below it. It occurs
Mfntnill) In children. It usually produces symptoms
i re pain, vomiting, tenderness and
(jllty i the abdomen. In well-marked cases a
l>r felt and blood is passed from the
|.m> • food is to be given. Local applications
i (Hum stupes are made over the abdomen.
ni» may be given by the surgeon or the bowel
i. liil ltd "I with air. If these means arc not
■ti,..h»l»l ,»! operation is the final resort The con-
<lili.ni i> Mrioui and needs the attention of a skilful
|
..*«< urinary calculi. If a stone is trying to
from thi the ureter or from the
.,,. || i Into i • r through the ureter, it produces
M a Dili an idinl Of rrnal cnlic. When a stone is in
ii, , .11 mi «" Operation becomes necessary,
,,a\\ I.U.I.Ui i- Qfitntd Md the stone having been
i .linage is carried out. The cutting
i atone from the urinary
hU. II Hi I .'i/a. <!.<»* y When the stone it crashed,
totfirj The patient should
OR TIIOI'.EDIC SURGE It Y
339
be kept dry and warm, and the back should be care- fully protected against the formation of bed-sores. A rubber pad to protect the bed is always needed in these cases.
After the amputation of a leg or ami the stump should be elevated on a pillow protected by a rubber slip. The nurse should always be on the look-out for haemorrhage from the stump, which would first be shown on the dressings, and later by con.siitution.il symptoms of shock. The bed-clothes should be pre- vented from coming in contact with the injured part by means of a "cradle." The dressings are generally removed in about ten days.
Orthopaedic surgery is carried out for the COinctlOfl of deformities in children and somewhat less often in adults. Practical demonstrations of the special forms of apparatus that arc necessary for such cases should form part of a nurse's training. Experience in the nursing of such patients can seldom be acquired in a general hospital, and any nurse who is especially in- terested in the subject should take a practical course in an institution which pays especial attention to this class of patients.
CHAPTER XIX.
Baxdaczs.— SvacicM. Euatcusats— Shock.— F«actvms.— Sl-mjcal Apfuascts— Di*locatioxs.— Shams.— Cox- tmjojc*.— Bt -i.\; and StAU». — Fmost-mte. — Foascv Bomz* ik jut Ens, Nose. Eajs, axo Laiyxx.
The principle* of bandaging, the variety of bandages and the indications for applying any particular form may be taught theoretically, but only by long practice can one become an expert in bandaging. A beginner not set ottt with the idea that the first essential in applying a bandape is to have it look well. The chief points to be taken into consideration in bandag- ing are—
1. The object of the bandage.
2. The kind of bandage and the material of which it
is made.
3. The part of the body to which it is to be applied.
4. The best method of applying it.
Bandages are used in surgery to keep dressings and applications in place, to make compression, to prevent motion, and to act as a support and protection. They are made of different materials according to the use tr. which they arc put. For hospitals, the substances chiefly in use are surgical gauze, bleached or un- bleached muslin, flannel and rubber. For private practice it is sometimes more convenient to us linen or muslin. These bandages vary greatly in the matter of pliability: unbleached muslin, for instance,
340
BANDAGES
is not so adjustable and docs not lie so snugly as gauze or flannel, and therefore more skill is required to apply a muslin bandage, .-.<> ih.it it will stay in place, and while being comfortable will also look well, than when gauze is employed. When we have a bandage to put on, we must always take into consideration the part of the body to be covered. This is important, not only because it will influence us in our choice of the bandage, but because we must always have some idea of the degree of pressure that will be comfortable, since some parts arc more clastic than Others, Any excessive tightness should be avoided, though allow- ance must be made for some loosening of the bandage later, caused by the moving about of the patient. The maintenance of an even pressure, sufficient finnttess, and comfort should always be kept in mind. We shall stand convicted of a disregard of this rule if when a bandage is removed from an arm, for instance, the skin shows little ridges separated by distances which just correspond to the width of the bandage; for the presence of these proves that the compression has not been made evenly, and that the bandage has been in some places perhaps uncomfortably tight and in others too loose.
Bandages are classified .»* simple and compound, the former being made of one, the latter of two or more pieces. The roller bandage is made in six, eight and twelve-yard lengths and of various widths. As gauze stretches more and is less bulky, bandages of this material should be rnndc both wider and longer than the muslin bandages uwd (oi the same purpose.
The average widths of muslin bandages arc about as follows:
fWKSING
nger, i inch; irm 01 head, 2^4 inches; lh« Ir|j, 3 to 4 inches, v. r~i to 8 inches. .gcs for the head, arm, or leg are made
, ||< Hfii
i pre, i'/s inches;
Uxly or for large dressings, 6, 8, or 9 inches. niiiitln bandages strips of the proper widths arc
I 1 I, the ravellings from the sides having been
ire wound tightly and evenly by hand or 00 <U|ft roller. The end of a piece of muslin with
p of the maker in blue letters should never be
1 unlet* it has been first washed, and a bandage
not be handed to the surgeon with ravellings of
l hanging from it. Some gauzes can be torn
1 11I rolled after they have been allowed to
• In, but, as a rule, gauze bandages have to be cut.
Unnilly u thread is drawn out as a guide to follow
1 ilng out each bandage, which is then rolled by
II II but where very many are used this procedure Irtln1* too long, and, although bandages made in this
lo not look quite so neat, a broad piece of gauze limy !» rolled on a large roller and then cut with a .|n.i|< loilfa Into the requisite widths. The wider band- NgM, inch a* thl ~ Inch and 8-inch widths, plaster-of- l',4ii» bandages and others which must be wetted, can
• llj be tolled on small round hard-wood
1 ni thrre-cighth* of an inch in diameter: this
in. ni prevent! them from doubling up and
y to apply.
I I I hamlagei when used to reduce swelling or
1 1 ni ..11 the bias, as made in this way
BANDAC
343
they are more elastic and it is possible to make firmer pressure. The rubber bandage is used to control hem- orrhage, for varicose veins, or for reducing swelling. For holding dressings or applications in place on a limb the simple roller is used, and should be put on firmly enough to prevent the dressing from slipping: the tension should be uniform throughout the course of
Fi«. 7.
HlIL-ItlT.
the bandage. The spiral and figure-of-S are the forms used for bandaging the limbs. The bandage should always he put on from the extremity of the limh to ward the trunk. It should be held firmly in one hand, .mi I applied with the outer surface next to the skin, and as it is unwound the roller should be held close to the part. The bandaging of the leg of a patient who is sitting is much facilitated by the employment of a heel-rest (big. 7).
XVKSWG
The single and double recurrent bandage (or cajv- line) ami the tigure-of-8 are used for the head. The Carton bandage is employed to keep the jaw in place. A recurrent bandage is also the one generally used for the stump after an amputation. For the axilla, shoulder, or groin the spica (either double or single) is used. For a fractured clavicle the Velpeau or Deaultl bandage is employed. The figure-of-8 is particularly adapted for application to the breasts; for the abdomen some modified form of the ScaltetUI bandage is largely used. The T-bandage keeps dress- ings in place on the perineum. Bandages intended to prevent all motion are usually made of plaster of Paris, starch, or crinoline, and of these the plaster-of- Paris bandage is most frequently used. To make plastcr- iria bandages it is necessary to have the plaster of an extra fine quality, without any lumps in it and to select either crinoline or gauze, since the meshes of these substances arc large, retain the plaster well, and such bandages arc readily moistened. The dry plaster is spread evenly on the gauze with a knife and smoothed over it by means of a tightly-rolled flannel bandage, and as the plaster is rubbed in, the bandage is rolled loosely on a small round stick. When finished these bandages are wrapped in paper, and kept in a tin box away from the air and moisture, though at best they are apt to de- teriorate soon. They arc much used in fracture cases. When they are to be applied, the limb is first bathed and powdered, then wrapped in folds of gauze, or bet- ter -till, covered with rolls of sheet cotton of a sufficient thickness to protect the skin from the plaster. Instead of gauze or sheet cotton cut into strips, a flannel band- age is sometimes wed, but it is liable to be unpleas-
345
antly warm and may cause irritation. A basin of warm water, a can of plaster, salt, and large rubber Sheet! to protect the bed and floor, arc required. The plaster bandages are put into the water and allowed to remain till the little bubbles of air cease to rise. This is a sign that they are thoroughly soaked, and they should now be wrung out moderately tightly. For the foot ami leg the surgeons usually begin by putting on two 4-inch bandages, and then for the thicker parts of the leg and thigh two 6 inches and one 7 inches wide. After the bandages have been applied a handful or more of plaster is stirred into the basin of water until the consistency is that of thick cream, and the mix- ture is rubbed smoothly over the whole dressing. The addition of salt to the water — about two drachms to the quart — will materially hasten the hardening of the plaster ; but this is not always used, for frequently the difficulty is to keep the plaster from hardening too rapidly. Melted paraffin painted over the exposed portions is sometimes used to protect the dressing from the moist wound secretions. When it is necessary to remove a plaster bandage it should lie em off with a stout sharp knife or scissors. This process will be found less difficult if the line of incision be moistened from time to time with dilute In drochloric acid or hy- drogen peroxide from a medicine-dropper.
Crinoline bandages are used to keep dressings im- movable: they should be rolled on sticks, wetted In warm water, and not too tightly wrung out, just before being used To make them even stiffcr, starch is sometimes incorporated into the crinoline. The starch should be boiled as for laundry use. the crinoline bind age dipped into it. wrung out. and applied. If neccss-
346
NURSING
.11 > mim starch can be rubbed in. The bandage sjtould be exposed to the air until dry: hot cans pi about it will hasten the process.
In addition to the spiral and Hgure-of-8 bandages and various modifications, we must speak of the triangular bandage, which is rarely employed in hos pita! practice except as a sling, but is very scrviccabl in surgical emergencies, as it can be more readily vised than any other kind. Two opposite corners of a large square of strong muslin measuring a yard or 40 inches each way arc brought together, and the square is cut into two equal triangular pieces. These bandages arc used for the same purposes as the roller bandage — namely, to keep dressings in place, to fix ■pilots, and for protection and support. A large un- cut handkerchief can be made to answer as well. The various methods of applying the triangular band- age are fully demonstrated in the ordinary books on bandaging.
Where small dressings are to be put on or appli- cations are to be held in place, and a bandage would be too large or cumbersome, strips of rubber adhesive plaster arc used. Splints on arms or legs are some- limi •■; held in place by this means, and in cases of fractured ribs, where the movements of the injured side are to be restricted, instead of a bandage, straps of rubber plaster arc applied halfway round the chest. The rubber adhesive plaster is very convenient, as it is always ready, and needs no special preparation bi being torn into the required widths and lengths and then rolled on glass rods. When rubber plaster is to W removed, it should be well moistened with alcohol, <>r ether, which loosens it somewhat and renders the
SURGICAL EMERGENCIES
347
process less painful Any remains of the rubber ad- hering to the skin can be easily washed off with alcohol or ether.
For practising bandaging the best opportunities are afforded by minor surgical cases in dispensary work, to which the nurses arc usually detailed in turns as assist- ants. In connection with this, a good book on band- aging, in which the various steps are all carefully demonstrated, should be obtained, and the methods studied out and practised on fellow-nurses and patient! until the requisite skill is acquired ; but it must be re- membered that it is not so necessary to keep to a pre- scribed figure as to have the bandage put on smoothly, firmly, evenly and comfortably.
Surgical emergencies. Next to that of the physi- cian, the presence of a trained nurse should be most valuable at the time of an emergency. While others arc standing shocked and helpless, her presence of minil will not desert her; she will at once suggest the ri^ht thing to do, and will proceed to do it in a cool and collected manner. The example she sets, in keep- ing her own nerves well under control, will go far toward steadying those about her and making them of some help to her. An emergency may be of greata or less importance; if it be only a minor accident, a nurse may be able to do all that is necessary for the time being, but in any case, unless the injury is clearly trivial, medical aid should be summoned at once, and if possible this should be done in writing, so that the sur- geon may know what to expect and may be enabled td save time by bringing wilh him whatever i* necessary. So much will depend upon tl>; nature of the cmer- • m \ that only general rules can be given, and a nurse
34«
NURSING
must Ik- guided fey these, together with the results
her nun experience. If a ruemorrtuge should !«.• the worst symptom of an injur,', it should be controlled at once before anything else is done, and if the pa tient is in a condition of shock, steps should be taken to revive him.
Hy shock is meant a general depression of the whole system produced in some obscure way which is at present imperfectly understood. This condition occurs after severe frights, accidents, and op or may be brought about by some strong emotion. Collapse and prostration are used to express sim- ilar conditions. Symptoms of shock should always be v, at. lied for after slight as well as after grave injuries. It is always the safest plan to keep a patient quiet for a time after any kind of injury, and the pulse thou Id be taken at intervals, because sometimes changes in it may be recognized when no other symptoms are apparent The symptoms to be looked for in shock are a weak, rapid pulse, a subnormal temperature, a cold skin, pallor, a pinched look of the face and about the lips, feeble or sighing respiration, and sometime! nausea. The patient must be placed with his head low, and stimulated by being enveloped in blankets, while hot-water bags, bottles, or cans are placed at tag hit sides, between the legs, and to his feet, the effects of these being supplemented by friction and by tbe use of whiskey or brandy internally. If the patient is unconscious, the alcohol may be given hypodcrmically. When stimulants can be administered by the mouth, a teaspoonful may be given in half an ounce of hot water every ten or fifteen minutes. Strang hot tea or coffee are also valuable. An electric battery should
FRACTUA'F.S
349
be ready for use, as a surgeon sometimes asks for it ; and ether and a solution of Strychnin may also be required. The latter drug is often used in various forms of shock, particularly after operations. It is usually ordi red t<. In given hvpodermieally in doses of from one-sixtieth to oiK-[v\iiitieth of a grain. An en- ema of hot normal Kilt solution is often ordered.
If the injury be to the bead, alcoholic stimulants are generally contraindicated, and should never be given without a special order.
l:ractures. — Fractures are very frequent emergen- cies, but when unaccompanied by a wound they do not. as a rule, require the .same degree of haste as cases of haemorrhage. The first thing to be done is to place the injured part in as comfortable a position as possible for the time being; then the clothing is gently removed, the seams being ripped rather than cut, beginning with the uninjured side first. A frac- tured limb must be handled as little as possible, as there is always danger of injuring the surrounding tissues or of lacerating blood-vessels with the sharp ■ or fragments of the broken ends. In raising a fractured limb one should never tak,- hold of it from al>ovc. but should slip the hands underneath, and. taking firm but gentle hold at two points a short distance from the fracture on each side, and all tin- while making slight extension with the hand on the distal side, so as to keep the ends from rubbing to- gethefi should lift with both hands at the same time llowl} SSd evenly until the limb is in the position re- united.
Fractures may be recognized by the following signs, some of which, however, belong also to di -locations:
MURSIXG
1. Pain;
2. Inability of the patient to move the limb natu:
3. Deformity t>r displacement, cither seen or felt by
l>.i--.ing the fingers over the seat "f pain ;
4. Crepitus, the grating sensation felt on rubbing the
broken ends together :
5. Abnormal mobility in the course of a bone ;
6. Swelling and discoloration ;
7. In hospitals the Roentgen Rays arc often used to determine whether a fracture or dislocation is present.
Fractures are classified according to the nature and extent of the break and of the accompanying injuries A fracture is said to be simple or complete where the entire continuity of the hone is severed with but little injury to the surrounding parts; it is called a com- pound fracture if not only the bone is broken, but a wound is made which extends from the scat of the fracture to the outside. Such wounds may lie caused by the injury itself or may occur secondarily from the protrusion of pieces of bone through the skin.
A comminuted fracture is one in which the l>one is shattered into a number of fragments. The term impacted fracture signifies that the broken end., have been forcibly driven into one another, and are thus fixed.
Fracture! may be multiple— i e. where the born- is fractured at two or more different points or where more than one bone is broken.
A complicated fracture la one associated with a seri- ous injury to some important adjacent part — e. g. a large vessel.
A green-stick or incomplete fracture occurs where
/•A\rr//.A7-..\
35*
ilk bone is soft ami bends, and is only partially frac- tured ; it is relatively frequent io children.
Fractures arc also described as transierse. obliijuc. or longitudinal according to the direction of the break.
The process of repair of fractured bones, while imi cuming directly into a nurse's work, is one of very great interest. At the time of the fracture and for a little while after, much blood is poured out in close proximity to the injury ; this subsequently coagulates, and forms a framework upon which new tissue-cells grow and divide. New 1.1. xul-ve^sels enter, lime salts are deposited, and in a few days the so-called callus is formed. The less the ends of the bones arc dis- turbed, the less will be the amount of callus. This first callus has for its chief function the keeping of the ends of the bones at perfect rest until they become firmly united. The union of bone requires from four to six weeks, and then the provisional callus becomes in part absorbed. Still, the injured part is somewhat weak, and is not to be depended upon too much, and care should be exercised for another month, while for the process to be thoroughly complete from six months to a year are needed.
In considering the treatment of fractures, we shall first speak of the care of the patient when he has to be
moved so distance In fore the injury can be all. tided
to properly. The principal point to bear in mind is to keep the fractured part immovable, and in such a posi- tion thai it may give as little pain to the patient as pos- sible: if this be done, there need he no hurry about having the fracture set at once. The limb should be supported with KUlK'thiug >ti<T and smooth, such as thin, narrow pieces of board or shingles, stout paste-
35*
WUA'S/A'G
board, or the bark of trees, padded with something soft, such .-!•• cotton, wool, hay, straw, or leaves, which can In- held in place by triangular bandages made of handkerchiefs or by strips of linen, muslin, ribbon, 01 whatever is at hand F&r the forearm two padded .splints, long enough to take in the hand also, should be applied, one to the front and the other to the back of the limb, slight extension being made by pulling i.ciitlv on the patient's hand. The splints should be tied on in two or three places, and the whole forearm suspended in a sling which should reach from the finger-tips to beyond the elbow. If it be the upper arm that is broken, it may be bound tightly to the side. For a fractured le» slight extrusion should be made from the foot, and the leg lifted on to a pillow which is tied firmly about it, or broad strips of wood may be padded and placed one on either side of the leg and tied securely. If the thigh is fractured, the splint should extend from under the arm to the ankle, being bound to the body and to the leg by means of long towels or pieces of sheeting applied at intervals.
For a fractured clavicle or collar-bone the patient is to be placed fl.it on his back, When he is b i be 11 a firm pad should be introduced into the axilla, and the arm hound to the side, with the forearm flexed across the chest: this will prevent the broken ends of the clavicle from rubbing together.
For fractured ribs a broad body bandage applied tightly, so as to prevent motion and dee]) breathing, is all that can be done besides keeping the patient quiet. The chief danger in the case of a fractured rib is th.it i. ne of the sharp ends of the bone may pierce the pleura or the lung.
FRACTURES
353
For a fractured jaw the teeth should be closed upon one another and a Barton bandage applied. Food .should be given with a spoon or through a tube in- serted behind the last molar tooth.
Pott's and Colics' fractures arc named after the sur- geons who first described them. The Colics' fracture is a fracture of the lower end of the radius within about an inch of the wrist-joint. A Pott's fracture is one in which the fibula is broken about an inch and a half above the malleolus. It is accompanied by a turning of the foot outward, owing cither to rupture of the internal lateral ligament or to the breaking off of the tip of the internal malleolus.
Fracture* of the skull are dangerous in proportion to the amount of injury to the brain resulting from them, and cerebral symptoms should be watched for. Little can be done by the nurse except to keep the pa- tient in a quiet, dark room, with cold applications to the head ; no stimulants arc to be administered, and a surgeon should be sent for at once.
The wound of a compound fracture must be treated antiseptically. If there be much swelling about a frac- ture, to reduce it lcad-and-opium lotion or fomenta- tions are sometimes ordered. After the swelling has subsided, a permanent dressing is usually put on. The bones are placed in the normal position by manipula- tion, and displacement is prevented by rendering the parts immovable by means of appropriate bandages.
To be able properly to assist the surgeon in the putting up of fractures, the nurse must be familiar with the necessary appliances, including splints and the different kinds of apparatus for making extension. Splints arc made of many different materials. Wood
23
ALA
are considered the best and arc meet gen- trattv ascd, altboogh for certain cases leather, wire. v* jflints nude of hard rubber are better.
■den splints arc made of varying thicknesses and *»e*. while pine, poplar, and willow arc best adapted Kw this purpose. Before being used, the splint shoulc be well padded with cotton- wool, or layers of gatu iihv be strapped to it by means of strips of adhesive r. The splints must be long enough to include the joints above and below the fracture, and arc held m place with bandages. Splints are spoken of as an- posterior. and lateral; we have also straight, angular, and curved splints.
Whalebone or strips of gutta-percha of various widths are sometimes padded and placed in dressings ivc them additional firmness and strength.
For fractures of the kg between the knee and ankle Mterof-Pfcris splint is often used as a permanent dressing. For fractures of the femur it is generally necessary to employ some means by which constant traction upon the leg can be kept up, in order to over- come the contraction of the muscles, which tends to dis- place the two ends of the fractured bone. One means if applying this is by the use of Buck's extension apparatus, of which several modifications have been introduced. The materials required for this exten- sion arc moleskin adhesive straps, bandages, a modified Yolkmann iHcle, die combined bed-cradle with pulleys, weights, and blocks for elevating the foot of the bed, so as to obtain counter-extension by utilizing the body- weight. These appliance! the nurse should have ready when the surgeon comes to put up the fracture. The straps should be cut as in Fig. 8, and slipped through
THE BRADFORD FRAME
355
the small cross-bar of wood ; each strap should fa- two inches wide, and long enough to extend up the side of the leg and to include at least the lower third of the thigh. The entire limb should also be prepared by being shaved and freshly bathed. The straps, may
Fig. 8.
Buck's Extiksiov Aj-miatus.
be heated for application by holding them over an alcohol tlamc or by pressing the non-adhesive surfaces against a hot-water can just before they arc to be used.
Where the movement of a limb is to be restricted, sand-bags arc used: these are made of ticking of dif- ferent lengths and covered with rubber cloth. The weight of the bed-clothes is removed by means of the bed-cradle.
The Bradford Frame. — By this surgical apparatus we are able to secure practical immobility of the whole hody. It consists of a rectangular frame made of gas piping a few inches longer than the patient for .vhom it is intended, the breadth equalling that from tip to tip of his shoulders. The frame is covered with two broad strips of canvas which are fastened around the piping in such a way that the CUIVM if Rtretdied tight. By these means the sagging which would occur with a mattress can be prevented. Between the two strips an Opening i* left which correspond.* to the position of
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NDBS1NQ Fra. B |
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1 I 1 l |
||
|
1 " 1 |
||
|
1 |
TBI BUDIOkp Pum |
OlSLOCAT/OXS
357
the buttocks. The patient lies upon the frame, to which he is confined by means of a towel pinned over the hips and by straps stretched obliquely over the shoulders. The opening is left so that the frame and patient may be lifted as one piece when it is necessary for him to be placed upon a bed-pan. These frames are used chiefly for hip-joint cases in children, when it is necessary that the child's body should be kept fixed while an extremity is undergoing extension. They arc sometimes very useful in cases of fractures, and aba for confining children when absolute quiet is desirable after any operation.
The various splints, forms of extension apparatus, braces for deformities and the different ways in which they arc used should be made the subject for special demonstrations in the class-room.
Dislocations. — A dislocation is the luxation or dis- placement of one or more of the bones of a joint. A dislocation may be simple, complete, compound, or com- plicated.
A simple dislocation is one in which displacement has taken place, with a minimum of injury to the sur- rounding tissues.
It is complete where the bones which enter into the formation of the joint are entirely separated from each other.
In a compound dislocation the tissues and skin arc torn apart, as in compound fractures. Besides these, the terms recent and old arc used ; in the latter, inflam- matory changes have, as a rule, taken place, which interfere with reduction. A dislocated folnl will pre- sent a deformed appearance, and the displaced bone will form a projection near by. Dislocations arc
358
NUHSING
very painful accidents, and in most cases there is 111 tie that a nurse CM do beyond supporting the par». and applying cold evaporating applications to keep the inflammation in check until the surgeon arrives. Sim- ple dislocations are usually reduced by manipulation or liy extension ; where there is much muscular resistance, chloroform or ether is given to complete anaesthesia. When a dislocation has been reduced, the part should be supported with bandages until the relaxed or torn ligaments become firm and strong again. A dislo- i .it ■ il jaw may be reduced by protecting the thumbs well, and then placing them in the mouth on the lower molar teeth on each side, and pressing firmly down- ward and backward, when the bones will slip into ;.'ace.
Sprains or wrenches of joints arc caused by a twist or by a blow which may be direct or Indirect ; the injury consists in the rupture of a greater or less num- ber of the fibres of the ligaments. The symptoms are severe pain. Inability to use the joint, swelling, heat, and later discoloration from effusion of blood.
For minor sprains the treatment consists in giving rest to prevent increase of the inflammation, clcva- ti on of the limb to lessen the blood supply, the of hot applications, or cold evaporating lotions to the swollen part, massage and support with a pad and firm bandage between times. Lead and opium lotion is frequently ordered. Gauze soaked in it
and applied, die part being covered with oiled silk to prevent evaporation. Where there is not much swel- ling a plastcr-of- Paris bandage is sometimes applied at once in order to secure absolute rest.
Burns, — Strictly speaking, I Raid is an injury to.
BUK.VS
359
the tissues produced by contact with moist heat, where- as a bum is caused by dry heat. Burns are classified as of the first, second, and third degree respectively, according to the depth to which the tissues arc in- volved. This classification, however, does not teach us much, as a burn of any degree may prove fatal through shock if a large surface of the body has been injured. A superficial hum, for instance, involving a third of the body, more especially if the patient be a young child, will almost certainly prove fatal, while a very deep burn, provided it be localized, may not be so serious, unless important nerves or vessels have been ■ !c - . .1 wiu'ic \ :nj ■!■ >ma of ihock are present, contitutional treatment should at once be institut. d. as the danger to life is great.
A bum of the first degree is one in which only the superficial laser of the skin is reddened with slight vesication ; burns of the second degree extend through the true skin ; while in those of the third degree the injury gOi ■! tin Mihcntaneous and involves the
deeper tissues.
After treatment of the shock, the next important
thing to remember is exclusion of the air, as this will
tend much to allay the pain. In superficial burns, where the skin is not broken, bicarbonate of soda Should be sprinkled thickly over the bum, the part wrapped in moist gatizc. lint, or linen, over which a layer of common cotton is applied and held in place with a bandage. Flour may be u<l instead of the hicarhonate of soda. These two remedies are easily obtained, and are efficient. The objection to powder of any kind where the skin is broken is that it forms into hard cakes and is difficult to remove. Applica-
Z*>o
NURS/.V(7
tionB in liquid form arc therefore better, or gutta- percha tissue, perforated here and there, may first be laid over the burn, and then over this a layer of cotton, which can be kept in place by a bandage or by a coat- ing of celloidin or collodion. If there are vesicles, they should be snipped open with sharp scissors or a knife at the lower edge, and the fluid absorbed with gauze or cotton spanges ; gauze or lint pads may then be wrung out of a saturated solution of bicarbonate of soda or boric acid and applied. For superficial burns or excoriations equal parts of zinc ointment and olive oil are very efficacious. The various oily dressings most frequently used are Carron oil, ointments of zinc oxide, bismuth, or boric acid, and simple or carbolized sweet oil. The ointments arc best spread on sheets of lint or protective, and changed before the odor be- comes offensive. Carron oil, which is made of equal parts of lime-water and linsecd-oil, becomes exceed- ingly disagreeable, and the oil in it stains the bed- linen. It is not so much in vogue as formerly. To prevent deformities from contraction, splints and band- ages are used. Where the burn heals by granulation, if the granulations become exuberant and wc have the so- called "proud flesh," they may be touched with a stick of nitrate of silver.
The system should be supported by a liberal light diet, particularly where there is much discharge. In connection with bums there may be brain disturbances, i |. lmiim or a nn-ningitts ; pneumonia and bronchitis are also complications to be watched for, and inflam- mation or ulceration of the intestines, particularly of the duodenum, occasionally follows. The feces should be examined, especially if there be any pain in the
\
tXNAUSr/OX MOM COLD
36.
abdomen. Sup] 1 or retention of the urine is not
uncommon. When the air-passages have been scalded by steam or hot liquids, the results arc generally seri- ous; the steam from lime-water, not too hot, may be inhaled to soothe the injured tissues.
Continuous warm baths arc now often used with \..r\ ^-ood results where the deep tissues arc involved and sloughs and charred material are to be removed. Where convenient, wc may begin with a warm tub- bath, with boric powder added to the water, which is excellent for its stimulating effects, for relieving the pain, and for cleansing the surfaces before the appli- cation of the dressings.
For burns from acids, bicarbonate of soda, chalk, whiting or some other alkaline powder is sprinkled over the surface of skin and covered with moist com- presses of gauze. Egg albumen is also used. Alkaline solutions arc applied if the skin is broken, and the main treatment is like that of other burns. For burns pro- duced by caustic alkalies, a mild acid solution, vine- gar or dilute acetic acid, is used. Where healing is slow or the raw area is very extensive, skin grafting is resorted to later on.
The nurse may meet with cases of sezrre exhaus- tion from exposure to intense cold. The symptoms are something like those of the later stages of intoxi- cation from th. aluiM' of stimulants. An bit drowsiness may result in coma, from which the patient never ftwekenB. In a case of frost-bite the vitality may he only parti.illv dettVO} ■! The patient should he kept in a cold atmosphere or put into a cold bath, and the part rubbed with snow or ice until sensation is Eel) tltd the color returns: the rubbing is then discontinued
jfo
KlKSfXC
and ice-water compresses arc applied. Stimulants, brandy, coffee, and hot drinks, are given, but external heat is only gradually permitted, since the restoration of the circulation can only come about very slowly in the frost-bitten parts, and in trying to hasten it too much we run the risk of producing, or at any rate increasing the tendency to, gangrene of the tissues.
Foreign bodies in the nose arc seldom found except in children, and consist of buttons, stones, or anything small and round that they can push in: they are not generally dangerous, although they are apt to produce inflammation if not removed at once. Peas or beans become enlarged after a short time by imbibition of water, and cause pain by pressure. It will probably be necessary to call in a surgeon, but simple means may first be resorted to, such as making the child sneeze, or by telling it to take a breath and then to close the empty nostril and mouth tightly and force the air out through the obstructed nostril. If these means do not dislodge the object, a small piece of wire may be looped around it or it may be syringed out.
Foreign bodies between the eyeball and one of the lids will cause a great deal of irritation, and in fact will soon vet up inflammation. If the particle In- sharp, like a sliver of glass or steel, it may become lodged upon the surface of the eyeball, it can be ex- tracted only by a surgeon; but when it moves loosely under the upper lid, as a rule, it may be removed by taking the upper lid between the thumb and index finger and drawing it well down over the lower lid, pressing it there for a moment, and then letting it slide back: the particle will generally be left on the
FOKEIGX BODIES
3*3
cheek. If not successful the first time, the procedure may be repeated, or the upper lid may be everted by turning it up over a pencil or any small rod and ex- posing the inner surface, so that the object can be seen and wiped off with soft linen or a camel's-hair [>encil. Sometimes it is possible to draw it up into a medicine dropper. Any irritation may be allayed by instilling into the eye a few drops of a half-saturated solution of boric acid; with children a few drops of a 1 per cent, solution of cneain are used to prevent them from shrinking during the process of extraction.
Another place into which foreign bodies Bnd their way is the external ear. They should be removed at once, as they are liable to cause inflammation. If a physician cannot be found, the nurse may attempt the removal by syringing out the ear, but unless she has had a great deal of experience she should never use a probe or forceps, since special skill is required in these manipulations lest the tympanum be injured or the object be pushed in still farther. If an insect should become lodged in the ear. a piece of cotton- wool should be saturated in a strong solution of s,dt or vinegar and the cavity completely filled with it. The patient should then lie on the car with the cotton in it, at the same time pressing the hand firmly "\ir it: the plug may be withdrawn after a short time, when the insect will probably be found on the cotton. Another way is to place the patient on the other side, with the affected ear upward: the tip of the ear is drawn up to straighten the tube, and warmed oil is poured in, when the insect will probably float on the surface of the oil. To syringe out the ear the patient holds the ear downward and the water is allowed to
364
XUAS/XC
run in very gently, being directed toward the upper and posterior part of the canal.
An obstruction in the throat is not very easily re- moved. Tlie first effoits ii.MiaUy made are to try to dislodge the object by striking the patient forcibly be- tween the shoulder! ndth the palm of the hand, or the child may be held head downward, and the slapping repeated. If the object is in the oesophagus or gullet, a drink of water or a mallow of bread may push it down. If not too far down in the throat, an attempt to remove it with finger, forceps, or an umbrella probang will probably be made. Anything in the air-passages may be coughed up. Fish-bones, if imbedded in the mucous membrane, must be removed with instruments by the surgeon. Even when a pin or bone has been swallowed, it may have scratched the mucous mem- bnne on its way down, and may leave the patient with a sensation which makes him believe that the foreign body is still present in the throat, so that even after a careful laryngoscopic examination has proved its absence he may still decline to be convinced that it has been gotten rid of.
If any hard foreign substance has been swallowed, :i is best to let it alone, as it will be carried through the alimentary canal. For anything sharp, such as a pin or piece of glass, purgatives should not be given, but. instead, the patient should be made to cat solid foods, such as bread, in which the object may become imbedded and be carried off without injuring or per- forating the coats of the intestines.
The Roentgen Rays, or as they arc more commonly Called the X Rays, are now used to a very considerable extent in hospitals for diagnostic as well as for thera-
THE ROENTGEN RAYS
3<»5
peutic purposes. By their aid it is possible to see through the fluoroscope and obtain by means of proper plates photographs of opaque bodies, so that fractures or dislocations of the bones, calculi, aneurismal or other tumors and enlargements of solid organs can be made out readily by an expert. The X Rays are now used successfully in the treatment of many skin lesions — acne, lupus and other superficial growths, even when these are of a cancerous nature. For deep-seated cancers or other tumors, however, they are not effect- ual so far as inhibiting the process is concerned, al- though occasionally they bring about more or less al- leviation of the pain.
CHAPTER XX.
H.fcMOKtUIACES.
I lamorrhages might properls In- classed under the head of emergencies, as they very frequently occur when least expected, and their treatment requite! prompt action coupled with presence of mind .md calmness. l!y word, sign, or look, a nurse should never let the patient know that anything unusual or dSltgeroU! ha> occurred hei mannei Should In- quiit and reassuring, though she should fully realize that the bleeding must be controlled as quickly as possible, and adapt her procedures to the necessities of each case.
H.cmorrhagc may be defined as the "escape of blood from :i:i\ purt of tin vasculai .. with or
without rupture of the coats of the vessel." Haemor- rhages are arterial, venous, or capillary, but in severe cases the bleeding may be from all three sources at once. When a hemorrhage occurs in connection with
wounds, it is called traumatic (relating to a wound
injury) ; when, however, it occurs as the result of a diseased condition, and is not directly attributable to violence, it is said to be spontaneous. The 1' blood may cause more or less danger according to the sire of the injured vessel and its distance from the heart. Haemorrhages may be external or internal, and arc to be combated by local or constitutional treat- ment, or by the two combined
366
HJF.MORR HACKS
3^7
The means by which the arrest of haemorrhage is brought about arc of two kinds: (i) natural and (2) artificial.
I hemorrhage from any of the large arteries is always serious and, unless checked promptly, sometimes re- sults fatally in a very short time. Arterial blood is to be recognized by its bright red color and by the fad that it comes out in spurts or jets corresponding in time to the contractions of the left ventricle, which force the blood through the arteries.
A venous haemorrhage differs from one which comes from an artery in that the blood is of a dark and pur- plish color and flows in a steady, slow stream; it is more easily controlled and less dangerous than an arte- rial haemorrhage, unless a large vein has been severed.
In a capillary haemorrhage the bleeding comes from the capillaries, which are interposed between the end- ings of the arterioles and the beginnings of the venule*. In this c.is. there is not so much a spurting as an oozing of the blood, which, however, at times may be very difficult to control.
The constitutional symptoms of a severe luemor- rhage are well marked, and. where the bleeding is in- ternal or comes from a wound covered by a large dress- ing, they may l>e the first to appear, and should therefore be carefully watched for. The pulse, which varies in frequency and t.-nsion according to the
amount of blood lost, will give us valuable information
as to the condition of the heart, and enable us to form some idea of the imminence of the danger. Where the haemorrhage has been severe, the lips have a pale, drawn look: the whole face is pallid and wears an anxious expression ; the pupils are dilated ; there arc
369
A'UftS/NG
signs of restlessness ; the body is bathed in a cold per- spiration and tlie extremities arc cold and clammy; the nails and finger-tips look blue, and the respirations gradually become weaker and shallower, until finally they are sighing; the patient complains of dizziness and extreme weakness ; the Speech becomes thick and unintelligible, or may even be entirely lost. These symptoms are followed by unconsciousness, from which, if the loss of blood has been very great, the pntii ut is never aroused, but dies in a state of collapse. Syncope or fainting is a desirable condition if it comes on early enough, as the bleeding ceases with it, and an opportunity is thus afforded for the blood to coagulate, by which means the mouths of the bleeding vessels are closed before the heart's action regains its normal strength. The coagulum which forms, when the blood-current is slow and the bleeding surface is exposed to the air, acts as a natural plug at the end* of the ruptured vessels. In the case of a vein, where there is no such propelling force to dislodge the clot, the vessel, as a rule, quickly closes, hut in arterial hemorrhage the plug formed is liable to be dislodged from the end of the artery with the subsequent heart- beats. Fortunately, however, Nature has provided for this, since the arterial walls have the power to contract and retract, thus lessening the size of the outlet and preventing the displacement of the clot.
In the arrest of luvmorrhagc by natural means the following factors are concerned:
1. Clotting of the blood ;
2. A weakened action Of the heart, sometimes shown
by fainting;
3. Changes in the vessels thcmscl-. ■
HAMONRH.U.t-S
By artificial means harmorrhage is arrested by — i. Position (elevation of the limb or part) ;
2. Pressure directly on or above the vessel, includ-
ing acupressure;
3. Forcible flexion;
4. Ligaturing or tying the ruptured vessel;
5. The application of heat or cold ;
6. Cauterization;
7. The use of astringent* or styptics, besides heat
and cold.
8. Torsion or twisting.
Pressure is of two kinds — provisional and perma- nent. In provisional compression, the finger is placed on the bleeding point, or, if it is an artery that has been ruptured, just above it, and kept there until aid comes. Permanent compression may he made by means of compresses and bandages fastened tightly over the wound, or by the Esmarch rubber bandage or the tourniquet applied at any point in the line of the artery between the wound and the heart tight enough to stop, or at least to much impi-dc, the cii dilation. To prevent bleeding from a limb during an operation an Esmarch bandage is tightly applied from
the extremity of ne limb to a point at some distance
above the scat of operation. Just above it. again, a piece of rubber tubing is tightly wound -<vcr.il timet round the limb and fastened. The Ksmarch is then removed. By these means the circulation will be so thoroughly arretted as to permit of a practically blood- less operation.
Acupressure is now but rarely employed. This meth- od i-. carried OQt by passing a pin or mvdlc tin the tissues over the artery, and again through the tis-
24
37©
NUfiS/NG
sues on ihc other side, thus making pressure on vessel. The pin is kept firmly in place by twistir silk or a fine wire over the point and the head of the pin in the form of the figure 8. The pin is usually re- moved in six or eight hours, after the clot has bccori firm.
Ligatures arc sometimes used in cases of accidental hemorrhage, as well as for tying the ends of vessels which have been severed during operations. The en< of the artery nearest the heart is picked up with a pair of forceps and tied firmly with a silk or catgut ligature. The latter is generally preferred in abdominal sur- gery where the wound is closed, as it is absorbed. Ligatures arc usually cut eighteen inches long. For tying ligatures the square or "reef knot" is used. The nurse should have ready for the surgeon, when he arrives, artery forceps, scissors, sponges, ligatures, and dressings.
Cold is frequently employed, as it causes the arterial walls to contract. Ice is the most convenient form in which to apply it: sometimes douches of ice-water are used, or cloths wrung out of ice-water and placed over the bleeding part arc sufficient where the hemorrhage is slight. An ice-bag half filled with pounded ice, lak over the parts in the neighborhood of the bleeding vessel, will sometimes serve the same purpose. Heat is seldom applied except in the form of very he douches for uterine hemorrhage, the temperature of the water being from 115* to 120° F. The actual 1, sometime* used during operations to check oozing, especially in abdominal surgery.
■Acs heat and cold. tlur. arc other styptics or I for the arrest of hemorrhage, which 'jrc used in
HMMORRHAGBS
37'
a powdcied or liquid form. In ionic cases, especially in nose bleed, a solution of adrenalin chloride is very efficacious. M onset's solution ol iron is very effective but dirty: it can be applied with a camel's-hair brush Or on a pledget of cotton or g.mzc. Sometimes the powdered perchloride of iron is thickly sprinkled over the bleeding point. Alum and tannic acid arc also well-known styptic*, and in nn emergency vinegar or common salt often does good service.
Torsion is performed by catching the end of the vessel with the forceps and twisting it two or three times.
Position and rest arc material aids in stopping bleed- ing, and where the hemorrhage is not very extensive, elevation ami perfect rest may be -ifnVient. By rais- ing the limb or the part, the force of the blood-current toward that point will In lessened, and the amount of blood lost will be reduced. This is something a nurse can always do at once. If the bleeding be from (lie abdumen. the font "f the bed ll lifted on to a low table or placed on two chairs, stools, or bricks according to the height desired. If it be from the leg. this should also be supported in an elevated posi- tion by pillows or by some other device. If it be from the forearm or hand, the par) is to be raised above the head ; or flexion of the forearm on the arm will often answer. A firm pad is put in the hollow of the elbow, and the forearm is bent tightly against the arm and held in place by a stout bandage. If the hem- orrhage comes from the leg or foot, the thigh is flexed upon the abdomen and the leg upon the thigh, and held firmly in this position as long as is necessary.
Rest should be maintained during and for some time
37*
AUKS/A'C
after a hemorrhage, as any movement will increase the heart's action and thus augment the flow of Mood, or where the bleeding btl stop]>ed it may bring it on again by displacing the blood-clot which is forming or has already formed at the mouth of the vessel.
Traumatic haemorrhages are classed as ( i ) primary, and (2) secondary. Primary haemorrhage is that whidl occurs at the time of the injury or operation. Secondary haemorrhage may occur at any time from twelve hours up to ten days or two weeks after the Operation or injury. It may be due to the slipping of a ligature or to :he separation of sloughs. Aft. amputation or a serious operation of any kind, where many large arteries h;ive been severed, a constant tratch should be kept during the first forty-eight hours, as there is always a tendency to h.Tmorrhagc during the period of reaction. A little oozing docs not neccssar- ;m .i .serious hemorrhage, but if the stain on the dressing continues to grow larger and is of a bright- red color, instead of becoming paler, then haemorrhage is taking place, and the mine must decide for herself whether or not the surgeon should be summoned at once. If she is douhnul. it is always better to be on the safe side. The pulse is probably the best guide. In a case of severe haemorrhage the dressings may have to be removed and the vessel tied. The nurse herself should never leave a patient who is having a haemor- rhage, but should send some one else at once for the surgeon, and in the mean time she should do what she can to control the bleeding by first exposing the wound to the air and making pressure over the bleeding point or in the line of the main artery leading to it. The part should be kept elevated, and, later on, permanent
HAEMATUklA
373
compression can be applied by means of an impro- vised tourniquet. This is made by placing a firm pad, such as a roller bandage, over the wound or just above it in the COUTH Of the artery, and then i\ ing l bandage or a handkerchief, folded diagonally, loosely around the limb; a short slick is next slipped under the k&Ol above the compress, by the help of which the bandage can be twisted as tightly as we desire. The use of the tourniquet, however, for any length of time, ifl liable to increase the tendency to shock, whereas prop- erly applied pressure over the bleeding point is gen- erally effectual and leaves no bad results.
Even when the bleeding has stopped it is sometimes necessary, in order to keep up the required blood-supply to the brain and respiratory centres, to lessen the amount in the extremities !.> bandaging them either with an Esmarch rubber bandage or with ordinary bandages tightly applied. Enemata of licit ■•all In tion or the subcutaneous infusion of warm salt solu- tion are often used by the surgeon, and should be ready on his arrival.
After the haemorrhage has ceased heat should be ap- plied externally. The patient should be kept quite free from excitement and in ignorance of the amount of the bleeding or the degree of the danger to which he has been exposed. The responsibility of giving the patient information on either of these points rests with the doctor, not with the nurse.
Haematuria, or blood in the urine, may have its origin in the kidneys, ureters, bladder, or urethra. If the blood be from the kidneys, it will be diffused throughout the urine, giving to the whole amount a uniform reddish color, Haemorrhage from the ureters
374
NURSING
most frequently results from tin- passage of a renal Calculus which has torn the mucous membrane. When the bladder is the source- of the bleeding, most of the blood comes away at the end of micturition in small clots, and one does not sec the intimate admixture of blood and urine which occurs in renal hemorrhage. When the haemorrhage is from the urethra, the blood precedes the flow of urine. These conditions should be noted by the nurse and reported, and it may be laid down as a general rule that when an evacuation of an unusual nature comes from any intemal organ, it should be kept for the inspection of the physician.
BpistaxU, or nose-bleed, is a very frequent form of haemorrhage but is rarely dangerous ; it may. how- ever, be difficult to check. The onset is not infrequent- ly preceded by n sense of fullness in the head, accom- panied by more or less vertigo. The chin should be kept elevated and the head never allowed to drop forward. If the bleeding il from only one nostril, the arm on that ride Is to be dented and ice-water or ice applied to the back of the neck and forehead. A t to 5000 solution of adrenalin chloride may be as a spray or applied on absorbent cotton. Ice- water or strong salt solution (l drachm of salt to 4 Oimce> of water 1 ma> be injected; finally, where all other methods fail, the nares must be plugged. A small soft rubber catheter, a piece of linen thread, or cord, and > small roll of lint or a sponge are needed. The thread is passed through the eye of the catheter, ami tin- catlu-tcr introduced through the nostril int the throat : the string is then caught with forceps and drawn out of the mouth, so that the plug or sponge can be attached : the catheter is then withdrawn fr
H.CMOh'KHAGES
375
the nose and the pledget pulled into position. The two ends which come from the nostrii are tied over a second plug which fills the opening. It is usual CO have the string long enough, so that after tying around the sponge we can leave an end to come out through the month on to the cheek, where it may he fastened with a bit of adhesive plaster. This facilitates the re- moval of the plug. The nurse is seldom called upon to adopt these measures, as the procedure is at times quite a difficult one, requiring the experience of the surgeon, and the foregoing description has been in- serted here chiefly that everything, which may possi- bly be required may be rcao\ n case of necessity.
I'.cchymoscs are due to extravasations of blood from small vessels into the surrounding cellular tissue, and usually follow blows and contusions.
To pack the rectum for hemorrhage a piece of gauze or lint is inserted, pressure being applied at the centre, so as to make a sort of hag. which is packed with cotton, (trips of gauze, or compressed sponges, the ends of the bag being allowed to project from the anal orifice. Within tin- Sphincter the rectum forms quite a large natural pouch, which requires a consider- able mass to fill it. This arrangement of the pack- ing makes its removal easy when it is no longer need- ed.
Uterine haetnorrh,i^r may occur from many causes — e. e, during pregnancy or after delivery, in various pelvic diseases, or as a consequence of operations. Those occurring previous to labor — antc-partum hem- orrhages— arc frequently connected with miscarriages or a placenta previa, A lerioui form of internal hemorrhage is that from rupture of the blood vessels
J7*
MUSING
in ectopic pregnancy. The patient generally plains of sudden and excessive pain in the lower abdo- men, and may speedily pass into a state of collapse. As a rule in these cases only a small amount of blood escape* from the vagina. The patient should be put to bed at once, kept perfectly quiet, and the physician sent for. Post-partiim hemorrhage will be considered in the chapter on Obstetrics.
1 hemorrhage from the genital tract after gynaeco- logical Operation* may usually be controlled at one by packing the vagina. Strips of gauze are prepared, the necessary instruments arc sterilized, and the pack- ing is done by the surgeon : until his arrival the nurse may give hot douches, as hot as 115* to 120* F. ; the foot of the bed is to be elevated, and the patient kept quiet. If the bleeding be profuse and the services of a physician eannoi be obtained, no valuable time should be lost, and the nurse must undertake the packing her- self. This can best be carried out by placing the patiettt in the Sims or in the dorsal position. The posterior vaginal wall is carefully retracted by means of a Sims' speculum, and the gauze is carried well up into the vagina by means of a long pair of forceps.
When a patient has fainted after a profuse hemor- rhage, the head is to be kept low, but no stimulants or
I dermics are to be given without a direct order
from the surgeon, since they increase the force and frequency of the hcart"s beat and tend to dislodge the clots, which may be forming at the mouths of the bleeding vessels. In rare instances, and where then is danger of collapse, the surgeon may think it best to Drdtt ttimulantl as being the lesser of two evils.
ArUrial haemorrhage, as wc said, is best arrested
IfsEA/OKft/iAGF.S
377
by pressure or by ligature. If the artery is imbedded deeply in the tissues and cannot be reached with the fingers, a graduated compress of gauze or lint is packed firmly into the wound and held in place by a bandage. The amount of ha-morrhage from an artery will depend upon its size and the manner in which it has been cut. An incised wound or one caused by a sharp instrument bleeds more than one made with a blunt instrument, where we have a contused or lac- erated wound, because the ragged edges of the torn artery and surrounding tissues retard the escape of the blood, so that clots tend to form more quickly.
To be able to control haemorrhage from arteries by pressure it is necessary to know the location of the principal arteries and how to reach them. The student nurse is expected to familiarize herself with the larger arteries during her study of anatomy, and with the manner of compressing them: the latter can only be learned by practising the methods after they have been demonstrated.
Venous haemorrhage is arrested by pressure below the wound — that is. on the side distant from the heart. Large veins, like the jugular, should be compressed both above and below the wound. This is necessary for two reasons: first, because the vein may bleed from both ends; and secondly, because (what i> held by many to be even more dangerous) air may enter at the proximal end and ctm' sudden death. Unless it be a large vessel which has been ruptured, the danger from a bleeding vein is not so alarming as that from the rupture of an artery of the same size, and compres- sion will usually suffice to check the haemorrhage. When varicose veins of the leg rupture, the limb
37»
S'UKS/.\G
should be elevated in addition to making compression. To prevent such an accident a rubber stocking il ally ordered, as it makes equable pressure along the vessel*, supporting t be walls and helping the circulation.
To control bleeding from the capillaries the wound should be exposed to the air. the part, if possible, ele- vated, and compression made by means of cold com- presses and bandages. This is not a dangerous form of Weeding, but is sometimes troublesome to control.
A kaenwrrhage dialhtsis is a predisposition to Need- ing caused by an abnormality in the structure of the walls of the vessels: in persons who bare inherited this abnormality, the slightest wound may result in fatal bleeding. Sometimes one will meet with whole families of tlwsc "bleeders."
For bleeding from the umbilicus in new-born in- fants, a little |>owdered perchloride of iron or alum be applied.
Internal haemorrhages may result from various causes: the most common ones arc those from the lungs, stomach, intestines, and pelvic orga
The blood in haemoptysis from the lungs is char- acterized by its bright-red color and the frothy ap- pearance which it acquires from the admixture of air bubbles; a spasm of coughing usually precedes it It the bleeding is flight, there may be some doubt whether it is from the lungs or not, since it may have come from the mouth or throat. TWa symptom is always more or less grave, but unless large blood- vessels arc involved it is not necessarily dangerous. The patient should at once l>. placed in the semi-re- citmbcnt position and kept perfectly quiet and free from Small pieces of cracked Ice may be svraj*
H&MATEMESIS
379
lowed whole or allowed to dissolve in the mouth, and a light ice-bag or an iced compress should be laid over the chest. The feet should be kq>t warm. The patient must be warned not to speak or to attempt to swallow food, since even these movements may increase the hemorrhage. The physician should be called at once, and he will probably, if the hemor- rhage be marked, order a dose of morphin. After any severe haemorrhage a warm solution oi Mirilizi-i. salt solution should always be prepared before the arrival of the physician.
Haematemesis means the vomiting of blood. The blood is generally ilark red in color, often resembling coffee-grounds, and is mixed with particles of food. The patient should lie down and keep quiet ; nothing should be given by the mouth but ice- water compresses or an ice-b3g may be applied over the stomach. The nurse should try and make sure that the blood has not originally come from the nose and been swallowed and afterward vomited.
Haemorrhage from the intestines, or tnterorrhagia, may come from raiiOM C*fltt9, frequently from ul- ceration of the coats of the intestine, as in typhoid fever, in dysentery, acute or chronic, from internal haemorrhoids, or from can taenia of the intestine. Cold in the form of cold-water injections or a piece of ice introduced into the rectum, ice-cloths or an ice-bag applied to the abdomen, are sometimes ordered, with elevation of the foot of the bed and perfect rest. Er- got is of doubtful value, but the physician may order opium, not only to control :h lallie action of
the intestines, but to allay the pain (if any be present) and at the same time to quiet the fear* of the patient
CHAPTER XXI. SdtcicAL On™ vhn<;- Rooms. — Nutst's I —How to
PU&\U. *OK Ol-EKATIOXS IN PklVATT. H0VO&
As the technique of the operating-room has come to have such an important bearing on surgical operations, and as the nurse is often depended upon to prepare everything required, and to see that everything in the room is in a condition of cleanliness and order, her duties in this special work will be dwelt upon in detail.
According to the plan outlined in the first chapter of this book, the bacteriology connected more particularly with the subject should be taught didactically and with demonstrations at the same time, so that as the pupil advances in her practical work she will understand the full significance of the unremitting absolute cleanli- ness, care and precautions against infection in relation to patients that arc insisted upon at each step. Thus by the time she has gone through a year and a half* train- ing in the hospital she should be sufficiently well grounded in the principles of asepsis to appriri;itr the full meaning and importance of the surgical technique which is carried out in all its minutix in the opcrating- KMBL
Surgical technique means the refinement of eleufl ncss applied to everything and every person that in any way or shape comes in contact with the field of op- eration; for success in surgery is quite as dependent UPOO a faultlessly aseptic technique as upon the skill
380
SURGICAL TECHMQUE
3««
of tlie operator. To entry this out is a simple matter in itself, bm there is always danger lest a lack of appreciation of the momentous results involved in each little detail may lead to carelessness and disaster. To bring about surgical cleanliness we may employ (i) Sterilization, by meant of dry <>r moist heat at a cer- tain temperature: (2) mechanical means — brisk scrub- bing with soap and water and a good hand-brush ; (3) chemical means — solutions of certain drugs which act as germicides.
Given conscientious attention to these details an operation loses nnieli of its elahora while the
results are gratifying. Uut let some one make a single break in these links of cleanliness and an in- fection, always more or less serious, sometim. s fatal, is caused by doctors or nurses. I'pon the nurse in a great measure depends the responsibility of carrying this surgical cleanliness into eff<
To ensure thoroughness in the antiseptic preparations, one nurse should be given the responsibility of the care of the operating-room — a task which !l usually suffi- cient to occupy her whole time. Any further assist- ance which is needed, should be rendered by the pupil nurses of the school, who receive their operating-room mining in this way. The pupil nurse thus work- un- der the direction, observance, and criticism of the nurs.- in charge, upon whom devolves tin tesponsihility of rendering surgically clean everything in the operating- room that is likely in any way to come in contact with \\ wound. This duty includes the care and sterilization of instruments, the preparation of solutions, ligatures. Mgs, operating-room limn (including the BUT gcons' operating suits and nurses' dresses), and the an-
3**
NURSING
tisqnic care of the room: all this work necessarily demands a thorough knowledge of the details of the preparation for any kind of operation.
The first step in the nurse's work is the care of the operating room. The location of the room is impor- tant, for the higher it is above the ground the less the contamination from the air and from the dust of the streets, and the easier it is to obtain a good light. It should not be too large, on account of the frequent cleanings that are necessary. The walls and the ceil- ings should be rounded ; there should be no angular corners. The walls may be lined with marble, but tiles or porcelain can be equally well cleaned. Where cheaper materials are employed oak or some plain wood should be painted with two or three coats of white enamel. There should be one or two large windows on one side of the room and a skylight to admit the greatest amount of light possible. The flooring should be of tiles or of paraffined hardwood, and should slant towards the centre or sides so that good drainage can be obtained. In the latter case there should be ilepn - sions in the floor at the sides to carry off the water. A flooring of white marble mosaic in three-quarter- inch imbedded m cement and then polished is ex- cellent,
In the Vienna Institute a Dutch-French substance called "Rlpolin" has proved very satisfactory. It has often been subjected to a temperature of ioo° C, and while the original white color has turned a little yel- low, blistering or scaling has not occured. Ripolin is, therefore, far more durable than white enamel paint.
The furniture is now usually made of glass or of enamelled iron. It should be as simple as possible.
THE Ol'liK.-l Tl SO- ROOM
3*3
There should be an operating-table, tables or stands for the instruments and the basins, the irrigating stand, and the stationary hand-basins, together with glass shelves for the various solutions and dressings, medi- cines and vessels. Connecting with the main opera- ting-room or adjoining it arc a set of small rooms which are to be used for the instruments, the sterilizers, the supplies in general, and for the preparation of band- ages, dressings ami solutions. Another room is set apart for the administration of anaesthetics. In this room there should be a narrow rolling table which holds the necessary outfit — the inhalers for ether and chloroform, the tongue forceps, sponges, towels, ba- sins, whiskey, brandy, strychnin, digitalis, atropin, aro- matic spirits of ammonia, hypodermic syringes and needles. This tray or table should be wheeled into the operating room and kept in readiness in case of an emergency. There should also be an oxygen in- haler, an electric battery, a Paquelin cautery and the apparatus for giving saline or other infusions. Dress- ing-rooms for the doctors and the nurses, a waiting room for the friends of the patients, a visiting room and toilet conveniences should be close at hand. Some surgeons prefer that the cleaning of the hands and forearms should be done in a room next to the opera- ting room. In this case a room fitted up with the nec- essary wash basins and provided with an abundant supply of hot and cold water is needed. The aseptic care of the operating room requires that everything should be kept in perfect order and quite clean. The walls should !><■ wiped down OOC« B week; the wood- work and furniture Should be washed with hot soap-
3 »4
A CAS/XG
suds each day, and the whole room well scrubbed fre- quently.
Whenever a patient in whom a septic condition is present has been operated upon, the operating-room and all its furnishings should be well cleaned and Wiped with a cloth soaked in a 1:20 carbolic acid solution. In addition to this the room should be well aired Some surgeons make it a rule never to Operate except in emergency cases for two or three days after dealing with an infectious or septic case. If it is possible to thoroughly close up the cracks in the doors and the window-sills, the room may be sterilized by means of the formaldehyde apparatus. This method, however, is relatively expensive and, unless thoroughly carried ■ nil. is not so efficient as the procedure mentioned above.
Sterilising Apparatus— AH well-equipped operating rooms have a sterilizing' apparatus. Steam heat un- der pressure in an autoclave is much employed. There should aUo be metal tanks for containing hot and cold water which has first been sterilized by means of a steam coil surrounding the under lining of the tank. Before this water is used for making the various so- lutions it should be strained into clean bottles through absorbent cotton placed in a glass funnel. If an auto- clave is not available for sterilizing purposes an Ar- nold steam sterilizer is all-sufficient, as it is quite large enough to hold bottles of salt solution, dressings or instruments. In a general operating-room not lesr ihm two of these sterilizers arc needed, each sup- plied with a Bunsen burner and gas tubing.
Dishes. — The dishes needed for operations vtrj i size and shape. They arc used to hold the various
/NSTKUMEfirTS
3«5
solutions for the disinfection of the hands and instru- ments, and some should be reserved for the reception of specimens. Those made of glass are decidedly preferable, but if these arc not obtainable, vessels of white porcelain or porcelain-lined ware will serve all practical purposes. When the porcelain begins to chip off a new vessel must be substituted, as it is impossible to be sure that a chipped dish is surgically clean. All such dishes, after an operation, should be washed in hot soapsuds, and then in clear hot water, being after- wards allowed to drain, since if they are wiped off bits of lint from the linen are apt to cling to the surface. The instruments are placed in dishes filled with steril- ized saline solution ; or what is still better, the dishes are rilled an hour before the operation with a 1 : 1000 bichloride solution, and just before the operation are emptied, rinsed out with sterilized water, and again filled with sterilized water, in which the instruments are received.
Instruments. — The operating-room nurse should fa- miliarize herself with the names of the instruments ordinarily used in surgical operations, and be able to select the sets used for the different cases. To pre- pare instruments for use, they are placed in a copper or porcelain-lined kettle filled with a one per cent, so- lution of sodium carbonate, which is allowed to boil for five minutes, after which they are lifted out and at once transferred to the dish containing the sterile solution. This is a very convenient method of preparing instru- ments quickly for a second operation. In order to prevent rust the instruments should be cleaned and dried immediately after an operation. The scissors and other paired instruments should be taken apart.
386
NURSING
1
They arc first washed and scrubbed very carefully in BWni soapsuds; any hUXntfa being removed with fine sapolio. Finally after being rinsed off in clear warm water, they are hoiled for five minutes, and then care- fully dried. The blades of cutting instruments and hypodermic needles should be wrapped in a thin layer of absorbent cotton to prevent dulling, The needles after being thoroughly dried should be passed through a double layer of gauze in which they remain until
needed again, instruments of aluminum ihould not
be placed in alkaline solutions.
Solutions. — In addition to the regular disinfectant solutions (carbolic acid and bichloride of mere other cleansing agents are now used in operating-rooms for various purposes. Of these the most important are salt solution and distilled water, which have superseded chemical solutions except for the disinfection of the hands and for septic conditions.
Normal salt solution, the preparation of whirl i p. described elsewhere, is used for infusions and irri- gations as well as for keeping the field of operation free from blood where sponging Is contra-indicated. Rub- ber tissue, which is to be used for covering skin-grafts, is kept in normal salt solution until it is to be ap; liesidei it-- i lean-.ing properties, this lolution hai been proved to act as a stimulant to the tissues, the red cor- puscles being preserved in it. whereat they ar.' ite stroyed by plain water.
Distilled xcater, when needed in large quantities, can be most readily obtained from ■ boiler-room, the steam from the boiler being allowed to condense. It is fre- quently used instead Of disinfectants for covering in- struments, and in the place of boiled water for pre-
LIGATURES
3»7
paring salt solution. Before the operation it is reheat- ed to whatever temperature is desired.
Suture Materials and Ligatures occupy an important place in surgery. Ligatures are of various kinds and sizes. They arc made of silk, silkworm gut, catgut, and silver wire.
To clean the glass reels or spools upon which liga- tures are wound, a good scrubbing with green soap and water and immersion in a 1:500 bichloride solu- tion for twelve hours is effectual.
Silk Ligatures. — The heavy silk ligatures arc cut into lengths of 100 cm., those of intermediate sire into lengths of 40 cm., and the "carriers," or those of fine quality, into lengths of 50 cm. Four strands of the heavy silk are wound together on one spool, ten of the intermediate on a second, and eight of the fine on a third red. For sterilization, a test-tube large enough to hold four reels is used, a little cotton being placed in the bottom of it. The tube is then plugged with cotton and steamed in the sterilizer on three suc- cessive days — for one hour on the first, and half an hour on each of the two following days. The spools are to be kept dry. and the plug must never be re- moved until the ligatures arc needed.
Catgut Ligatures. — Catgut, if it could always be depended upon from the standpoint of sterilization, would hold the first place as a ligature and suture ma- terial as. when buried in tin- ti.-r.-. in \W- ...1.1 ., ,,f time it becomes absorbed Tin 1 YmioI method of ster- ilizing catgut, as recommended by Kronig and modi- fied by Gark and Miller, has been proved to be the safest. The method is as follows :
I, Cut the catgut into the desired lengths, and roll
388
xua-s/xg
twelve strands in a figure-of-eight form and tic. so that the liiuiillr i-;m In slipped into a large test-tube.
'2. Place the tube in a hot-air oven and bring the temperature gradually up to 80° C. and hold at this point one hour.
3. Immerse the catgut in cumol ; surround the tubes with a sand-bath ; raise the temperature to 1650 C, and maintain it at this point for one hour.
4. Pour off the cumol. and cither allow the catgut to dry by means of the heat of the sand-bath, or trans- fer it to a hot-air oven at a temperature of 100 * C., until all of the cumol is driven off. This substance is very inflammable.
5. Transfer the rings with sterile forceps to test- tubes previously sterilized as in the laboratory.
Catgut both plain and chromicized, prepared by Van Horn, Kiliani and St. John Lea vans, can be procured ready for use in sterilized scaled tubes.
Silkworm gut is cut into lengths of 30 cm., doubled, placed in tubes, and sterilized in a 1 per cent, soda solution for five minutes in the same manner as silk ligatures.
Silver wire should be boiled. In dealing with any of these prepared ligatures, thorough antiseptic pre- cautions must he observed ; the hands must be carefully prepared, as if for an operation, before touching them, and nothing which is not sterile should be allowed to come in contact with them.
Drainage. — For drainage, rubber tubing of various sizes or strips of gauze and glass tubes are used. The game should be cut "by drawn thread" into strips of about a yard long and an inch wide, each of which is made into a little roll: four or more of such rolls
DA-£SS/.VGS
3*9
should be enclosed iii a glass tube and sterilized in the same way and for the same length of time as silk ligatures. For the same purpose strips of iodoform gauze should be kept ready cut in proper widths. When tubes or materials for gauze drainage arc used at a dressing, all handling of them should be avoided. They should always be handed to the surgeon b\ means of sterilized forceps. Rubber drainage-tubes arc prepared by scrubbing them well with soap and water and rinsing them in boiled water. They arc then soaked in a 1: 1000 bichloride solution for twenty- four hours, after which they are placed in a 1:20 car- bolic-acid solution for twenty-four hours, and finally kept in a 3 per cent, carbolic-acid solution, which is to be changed weekly or at least every ten days. Just before they are needed they are boiled in soda solu- tion. Glass tubes are boiled and kept in a i: jo car- bolic-acid solution, and washed off ifl alcohol before being used.
Dressings are furnished chiefly in the form of rolls of gauze, common or absorbent cotton, or pads. The gauze, which is most generally employed, should al- ways be kept ready, rolled in six-yard lengths, tnd folded so as to have a width of about nine inches. From these rolls pieces of any size required can readily be cut off. Fads are of various sizes and shapes according to the special requirements of each case. All dressings must be wrapped in towels and sterilized for half an hour before being used. Those that are to be kept on hand some time should be well dried after they have been sterilized and kept in closely covered jars.
The use of silver foil as a dressing for certain kinds
390
xa/fs/AG
of wounds has within tin- past few years come into favor with surgeons The foil comes enshcathed in papert, Before being used the packages are wrapi in towels and sterilized in the autoclave.
Sometimes gauze is used as a medium for holding chemical substances, such as iodoform or permangan- ate of potassium.
To make iodoformized gau:e.— Take of
Salt-solution soapsuds. 180 cc. (jjvi)
Iodoform powder 40 cc. (5x)
Sterilized gauze 3 yards
Mix thoroughly. Fold the gauze lengthwise with a
width of nine inches and dip into the mixture. Rub the solution well into the meshes. When the gauze is thoroughly impregnated, place it on a clean rubber eJotfl and roll it up loosely. Keep in colored glass jars.
Permanganate gause. — Plain gauze is cut into suit- able lengths and sterilized for an hour. It is then dipped into a solution consisting of hot water, 1 litre (Oij), potassium permanganate, 10 grammes (grs. d.). It is then rolled, as in the case of the iodoform gauze, and kept in a porcelain or dark jar. In pre- paring gauze the hands should be sterilized as for operations.
Absorbent cotton is cut into uniform sizes. It is then wrapped in a towel, and the bundle having ken securely pinned together is sterilized in the autoclave.
Rubber tissue is used for'proteeting wound) and fur securing drainage. It can be sterilized by being boiled in the soda solution.
Sponges for general use are made of gauze, small
Sro.vc/is
39<
squares being cut and the corners folded in. so that small round puffs are iniule. Fur abdominal work the sponges are made Hat and of several thicknesses. At one corner of each a tape is attached, which is caught in n pair of artery forceps, when the pad is placed in position in the abdomen. In preparing the sponges for abdominal operations bundles containing one dozen of assorted sizes are the most convenient. Each bundle, fastened with a safety pin. is wrapped in a small towel and sterilized. Owing to a miscount a sponge has oc- casionally been left in the abdominal cavity. To avoid any responsibility for such a mistake the mirsc should be particularly careful always to have the correct num- ber of sponges in each package. It is true that the surgeon is ultimately responsible for everything that he places in the abdominal cavity, but the making of the sponges and the counting of them into packages is distinctly the nurse's work. The only safe method lies in the employment of a rigorous routine. At the time Of the operation, before any sponges are used they arc counted, and if the number tallies with that of the nurse, she is relieved from any further responsibility. Finally before the abdomen is closed, a recount sh ■ ■•■: always be made by the surgeon, and the number must correspond with the original count. To have a fixed number — a dozen in a package — and to have as few packages as possible, will simplify the matter. A rec- ord ihoold be made of the number of packages, and the number of sponges in each package at the first count. Sea-sponges are now seldom used. They may be prepared by first pounding tluni well to remove the sand, and then washing them several times in water. Thes are afterward- soaked in a saturated toluti
NURSING
permanganate of potassium, decolorized in oxalic acid (sat. sol.) or dilute Sulphuric acid, again washed thor- oughly in warm water and placid in :i weak solution of dilute hydrochloric acid (two drachms to a pint of water) for twenty-four hours. After iliis they are washed in water until the washings are clear, placed in a bichloride solution (i :iooo) for twelve hours, washed in hot water and finally kept in a 3 per cent, solution of carbolic acid. Roiling destroys the elasticity of the sponges.
Iodoformizcd glycerin and iodoformized oil gener- ally contain 5 parts of iodoform to 100 parts of glyc- erin and oil, respectively :
lodoformised Glycerin. —
Iodoform ... 5 grammes (grs. lxxv) Glycerin ...100 cc. (3iii circa)
Mix and place in a wide-mouthed, thin glass flask, and sterilize for one hour, plugging the flask afterwards with sterilized cotton. When glycerin is used alone it is sterilized in the same manner. These solutions are used for injections into tuberculous joints or sin- uses, and in preparing gauge packings.
Two kinds of celloidin solutions are in common use:
Celloidin Solution (bichloride 1: 16,000). Ether (Squibb's),
Absolute alcohol. 55. 200 cc.
Of a solution of bichloride of mercury (grm. 1
dissolved in absolute alcohol 40 cc.), 1 cc.
Mix, and add of Anthony's "snowy cotton" sufficient
to make the consistency that of simple syrup. This solution is used chiefly for sealing woumN. For iodoformized celloidin. 25 grammes of iodoform
LINES
393
powder are substituted for the bichloride; the powder and alcohol are first mixed together, the ether is then added, and finally the cotton.
Linen. — The operating-room linen list calls for sheets, small pillow-caM-s, inml> for general purposes, small crash towels for the ether cone, cotton half- sheets, blankets and rubber sheets. A certain number of towels should always lie kept in a i:iooo solution of bichloride of mercury. Sterilized half-sheets can be used for spreading over the rubber which protect th< blanket covering the patient; for tins purpose they are much more convenient than a number of towels. The nurse should also sec that the white cotton suits worn by the surgeon are kept in repair, and that clean ones arc ready on each operating day. Her own dress should be of the same material, made with plain waist, skirt and belt, the sleeves being cut off just below the elbow. All these articles must be sterilized.
Methods and details differ somewhat ; every surgeon has his own preferences, and the nurse must of course carry out his directions. Those given hen- have been thoroughly tested and may be followed when no others are ordered,
Every large general hospital has at least two operat- ing-rooms— one for general surgery, and another for gynaecological operations, each main operating-room having a second, smaller room in which septic cases can be dealt with. In the gynaecological operating- room there should be an abundance of perineal and abdominal bandages, packing and tempons. Long stockings made of canton flannel are needed to put on the patient during minor operations. For abdominal operations, the half sheet should be made with an
J 94
tUfisjyc
opening down the middle, long and wide enough to allow of a full exposure of the held of operation. Some- times squares of sterilized gauze slit in the center are used for this purpose and thrown away after one operation, but the sheet can be washed, and is therefore more economical; moreover, it stays better in place, and as it cover* a larger area, fewer towels will be required.
As an abdominal section may be performed in either operating-room, we shall take this procedure as afford- ing a good example of the steps to be taken in pre- paring fur an operation.
The preparations should be begun in good time so that everything may be in readiness at the hour ap- pointed. The temperature of the room must be regu- lated, so that it v. ill be 80* F. at the time of the opera- tion. On the table should be placed a felt pad or a folded blanket sufficiently large to cover it ; next I pad comes a rubber sheet, and over this is spread a white sterilized sheet. In some operating-rooms elec- tricity is used to warm the top of the operating-table. A small air-pillow or one stuffed with hair is put where the bead of the patient will rest
The operating-room dress having first been put on. and the hands and arms having been vigorously scrubbed with soap and hot water, the regular prep- arations arc begun. The instruments, ligatures, and dressings are put in the sterilizer; the various basins En the solutions and instruments are conveniently ar- ranged on extra tables round the operating-table ; the salt solution is heated in its flask over a Bunscn burner. After this the hands and amis are again prepared, so that the BUM may be ready to sponge a wound or
SURGICAL TECHNIQUE
39S
assist the surgeon in oilier ways in his manipulations. Finally a fresh sterile gown and rubber gloves arc put on. In the preparation of the hands and forearms, they arc scrubbed for ten minutes with warm water and borax soap or green soap, particular attention being paid to the finger-nails ; they are then immersed in a saturated solution of permanganate of potassium for one minute, decolorized by being soaked in a satur- ated solution of oxalic acid, rinsed off in distilled water and finally immersed in a solution of i :iooo bichloride of mercury for five minutes. After this constant vigil- ance should be exercised that nothing whatever is touched that is not sterile; the assistant nurse or the orderly must be called upon to do any carrying or lifting.
Just before the operation, the instruments are lift- ed from the sterilizer into basins containing the solu- tions. After the patient has been arranged on the table, properly protected with blankets and rubber sheets, only the parts to be operated upon being ex- posed, the articles for final preparation are handed tO the surgeon by the assistant nurse. These consist of a basin of warm water, green soap, an crub-
bing-brush. After the field of operation has been treat- ed with these, ether or 95% alcohol is poured over it, and finally an abundance of a 1 :iooo bichloride solu- tion. Plenty of dry sterilized towels must be at hand ; M those in the proximity of the wound become soiled, they must be replaced by others which have been previ- ously sterilized, and placed in basins containing warm solutions.
After the operation il finished and the dressings are in place, the patient should be wiped dry with a warm
39*
MUttS/XG
towel ami then wrapped in hot blankets which should be closely tucked in about the neck, the sides of the body, and the feet. She should be taken quickly to an adjacent warm room where a bed has been especially prepared for her.
To Prepare for an Operation in a Private House.
In view of the greater risk to the patient's life, now- a-days only in emergencies arc major operations per- formed in private houses. In such case* not a few difficulties nay be met with in carrying out antiseptic preparations, but the majority of these can be readily overcome by the exercise of a little common sens ingenuity. A nurse should have at least a few hours' notice, so that she may have sufficient time to make preparations. She should select the room, unless the surgeon has not already done so, with a view to secur- ing proper light for the operation: It must be con- venient to the patient's bed-room, and an open fire- place is very desirable. Carpets, hangings, and all un- necessary furniture should be removed ; the walls should be brushed down, and the floor washed. If the carpet can not be removed sheets may be tacked over it. If household vessels be depended upon, all pitchers, basins, and towels should be boiled for an hour in a 2 per cent, solution of carbonate of soda or a i -40 carbolic-acid solution. The table is usually the pine one from the kitchen, and must be scrubbed off with green soap and hot water. Two or three smaller tables covered with sterilized towels arc needed for the basins. These, together with two or three plain chairs, arc all the furniture necessary. There should be plenty of hot and cold water, soap and towels. The cold water
k
OPERATIONS IN PRIVATE HOUSES
597
must first have been boiled and then kept in thoroughly clean vessels. There should be plenty of jars or pails to receive the water that has been used. The surgeon usually brings his own dressings and instruments, and other details should be carried out according to his directions.
CHAPTER XXII.
Gvn.i:colocy.— General and Special Preparation of Pa- tients tor Examinations and Operations. — Positions. — Instruments and Dressing* —Care After an Abdomi- nal Section, and Minor Operations. — Gynecological Terms and Definitions.
Now-a-days the treatment of gynaecological patients is so largely made up .of operative procedure*, that the preparation of such patients for operation and the after care of them by the nurse require some especial teach- ing over and above what she has had on the subject of general surgery. The anatomy of the pelvic organs, their functions and relations to each other, should be well understood by a nurse, in order that she may have an intelligent comprehension of the features peculiar to this work. She must be able to recognize the impor- tance of any physical change that may take place in her .patients, whether before or after operation, and must be familiar with the instruments and nomenclature used in this department of surgery. Education in this branch of nursing can hardly fail to impress ;i woman with the importance of using her influence among other women to bring about a broader knowledge of their physical con- struction, so that they may have a better appreciation of the general laws of hygiene, and more especial!) of those applying to the pelvic organs.
Treatment of gynecological cases may be genera SM
PREPARATION FOR OPERATIONS
399
local, or both general and local, but in the majority of hospital cases some operative measure in addition is generally indicated. The general treatment con- sists in putting the patient to bed and keeping her perfectly quiet, both mentally and physically. Am peculiarities in temperament or behavior should be noted and reported, as even a slight mental disturbance may be so aggravated by fear or shock that an acute maniacal or melancholic condition might follow an operation, and when in possession of all the facts con- nected with the case the surgeon will be able to judge whether operative treatment is advisable.
The nurse's duties before an operation arc to sur- round her patient with a quiet, cheerful atmosphere, to keep from her any causes for excitement, and build up her system by special attention to the diet,- giving milk in abundance and plenty of simple nourishment in an attractive form. Such a patient should have plenty of fresh air and sleep; all arrangements for the night should be finished by 9:30 p. M.. the lights turned low, and the patient left undisturbed, when, as a rule, she will quickly go to sleep. If she awake during the night, a glass of hot milk, cocoa, or broth should be given. Frequently with this form of treatment arc combined some local measures, such as the making of applications by the surgeon. When this must be done, the nurse should know just what is necessary to have on hand, and she must avoid any awkward delay, which may be very trying to the patient, especial- ly if it be her first experience of the kind. It will also fall to the lot of the nurse to make proper prepara- tion* for the examination of the patient and assist
400
HURSINC
the surgeon, all of which should be done in a quiet, dignified ami thoroughly professional maimer. The nurse's deportment will go far toward reassuring the patient and helping her to restrain any signs of nerv- ousness that she might otherwise he inclined to show, and which would prevent the surgeon from proceed- ing with his work. The nurse should always he present during the doctor's professional visits unless there should be any special reason to the contrary.
Before either an examination or application it is the nurse's duty to sec that her patient is in a presentable condition. She should take care that the rectum is empty and should give a general sponge-bath or tub- bath and, if ordered, a vaginal douche. For this last a I per cent, solution of carbolic acid is usually employed. A fresh night-gown, stockings, and a wrapper are to be put on unless the examination or application is to be made in bed, when the wrapper is not necessary. For a digital examination all that is required, if the patient is in bed, is to have her moved over to the side of the bed which the surgeon prefers, where she is made to lie on her back with the knees drawn up. The covering should not br» too heavy ; a sheet is enough. A chair is placed at the bedside for the doc- tor, and a towel and some vaseline must be ready. A l:i- m, containing water, should be placed on the wash- stand, and a nail-brush and soap. Examinations ether are usually made in the operating room: the |ir.-p:itatiOM are. tin- -.ami- U UlOSC just described.
For applications the patient is to assume the most convenient position.
The several positions necessary to know are the left lateral, the dorsal, the knee-chest, and the upright posi-
_
GYNAECOLOGICAL POS/T/O.S'.s
4OI
tion. In the first, usually called the Sims position, the patient lies on her left side and chest, with the left .urn drawn behind her and her head and right arm toward the right corner of the table, the buttocks renting well over toward the left lower corner; the legs should be flexed and the right knee drawn up above the left. This is the position usually ordered for applications re- quiring the use of the speculum, as the uterus and an- . tenor wall of the vagina are well forward and a better view is obtained.
Vaginal examinations arc made under cover and the dorsal position is the one generally adopted for these and for operations, whether capital or minor. The patient lies flat on her back, with the knees flexed ; or the legs arc otherwise arranged according to the nature of the operation.
In the knee-chest position the patient lies upon the side of her face, with her arms outstretched and her hands grasping die upper end of the table. The chest is flat on the table, the hips arc elevated, the back being bent in opposite the lumbar region, and the weight of the body resting chiefly on the knees. This position is UMiaQy chosen for replacing a retroflexed uterus and for making applications to the uterine cavity or to the vault of the vagina. The Sims speculum is the one generally used.
For the upright position, the clothes of the patient arc adjusted by folding the vk-irts about the waist, then wrapping a sheet about the waist ami I'm, i extremities, allowing an opening at the side. The patient standi with the right foot resting on the rung of a chair or on a low stool. In this position pessaries arc some- times inserted and examinations made, u
4oi
S'URSfXG
Sheets or blankets, in addition to the patient's own clothing, are generally used as covering.-, ami should be arranged so that the patient is quite covered until everything is ready, when only the part to be operated upon should be exposed. For vaginal operations two or three thicknesses of gauze of sufficient size to ex- tend from above the pubes to below the perineum may be wrung out of a disinfectant solution and spread over the parts: the operator works through a slit in the gauze, the opening being made sufficiently large so as not to interfere with his manipulations. Although this plan has not yet been generally adopted, the idea seems to be a good one. Long canton-flannel stockings reaching to the thigh.* nIkhiU be worn under the sheets that arc used to throw over the legs. For examinations under anaesthesia it is necessary also to have picnty of towels, a good supply of hot water, ether or chloro- form with inhaler, basins, specula, uterine dressing- forceps, cotton, and disinfectant solutions.
Frequently the nurse is required to hold the Sims speculum: she should stand on the left side of the patient, allow the left arm to rest lightly on the pa- tient's hip, and with the hand separate the buttocks near the vaginal opening ; with the right hand she grasps the speculum, holding it steadily and firmly as directed by the operator. The speculum should be placed in some warm solution or in vaseline before being introduced.
The local dressings generally in use consist of pack- ings of gauze and tampons of various kinds. The gauze is cut into strips about sixteen inches long and two inches wide. The plain sterilized gauze may be all
TAMPONS
403
that is needed for this purpose ; at times iodoformizcd gauze or gauze prepared with certain other chemicals may be desirable. Such packings arc usually left in for from twenty-four to thirty-six hours, and arc then re- moved with forceps, care being taken to make sure that every piece has been taken away by ending the procedure with a digital examination, as any gauze left in is liable to become foul and cause irritation.
Tampons are made of absorbent cotton or of lamb's wool. The cotton is cut into strips about eight inches long, four iiicho -.vide, and half an inch thick- tdl strip is then doubled, the ends are rounded off with the scissors, and the whole is tied securely in the middle, where it is folded, with a piece of stout linen thread, lengths of about six inches being left, with the ends knotted together, by which the tampon may be re- moved. Tampons arc used as supports to take the place of pessaries, and for applying local antiseptics, powders and soothing drugs in inflammatory condi- tions. When the walls of the vagina are to be kept apart lamb's-wool tampons arc used, as they arc non- absorbent and do not become sodden. They are made by twisting around three fingers a piece of wool 30 cm. long and 3 cm. wide, so as to form a loop ; a piece of linen thread is tied around the center of the loop, leaving long ends to the threads as described. The wool is then spread out flat. When a tampon is to be placed in the vagina the posterior surface of the small blade of a Sims speculum is anointed with sterilized vaseline, and the speculum is carefully introduced. Gentle traction being made upon the pOttoiot Vlgill*! wall by means of the speculum, the tampon can then
4-4
SUJiSl\C
be introduced wits a pair of lonjj dressing- forcep* into the anterior or posterior cul-de-sac of the vagina. Usually an order i* given to remove a tampon after twelve to twenty-four hours, and to follow its removal with a warm douche.
If a Hodge pessary, or one of a similar type, is to be removed, two fingers of the left hand arc introduc-d into the vagina, and the index finger, being hooked over the anterior bar of the pessary, which rests against the upper portion of the symphysis pubis, gives it a half turn: this frees it from the cervix, and it only remains to remove it from the vagina. The penary should be placed, after removal, in a 1 : 40 car- bolic-acid solution for five minutes, then well washed off and dried.
For making the general dressings in a gynaecological ward, the necessary instruments to have ready are a Sims speculum, uterine and ordinary dressing- forceps, a uterine sound, probe, tenacula. curettes both sharp ill. Indict forceps, applicators, cotton-holders, and a pair of straight scissors. These should be sterilized ready for use, and in addition there should be a drcss- mg-linskn or carriage containing a roll of sterilized pose and absorbent cotton, vase!im\ tampons, pessaries and the standard solutions and ointments, also the various disinfectant powders, such as iodo- form, boric acid, and astringents. Rubber strap- ping wound in strips on glass rods, perineal and several Bed Seultdai bandagei (Fig. 10), should be ready to hand, and plenty of basins, hot solutions and towels are among the things required.
For minor operations the preparation of the patient.
MIXOK OPERATIONS
405
with n few modifications, is practically the same as for an abdominal section. Twelve hours before the opera- tion, the physician usually orders a tub-bath or a
.'.--bath and the administration of a cathartic; on the next morning the patient must take no breakfast:
'i'HiU receive a simple soapsuds enema, which should be repeated until effectual. The parts must
Fie. 10.
MODirilD Scclt*tu» Basdaci
then be shaved ; it may be necessary to go over the sur- face with the razor two or three times, in order that the finest hairs may be removed. When this has been done, the parts must be thoroughly scrubbed with green soap and water, washed off with alcohol and afterward with ether, and finally sponRed with a 1 :5ono bichloride solution. A compress of sterilized gauze
406
NUXStNG
wrung out of warm bichloride ( i : 5000) is next put on, and held in place with a sterilized abdominal binder to which are attached perineal straps, to keep it from sliding out of place.
The After-core of an Abdominal Section Case.
In the care of a patient after an abdominal section, before the patient is removed from the table some operators order an enema consisting of a litre of warm sterile normal salt solution given with the patient in the Trendelenburg position. The good effects result- ing from this procedure are manifold ; it tends to re- lieve the thirst which follows abdominal operation* : it stimulates the kidneys and thus increases the secre- tion of urine while at the same time it lessens the irritation of the bladder and prevents retention ; it also has a general systemic effect. Sometimes one- thirtieth of a grain of strychnin sulphate, twenty- four grains of ammonium carbonate and half an ounce of brandy are added to the salt solution. For the first twenty-four hours, very little can be done except keep- ing the patient quiet, watching the pulse, looking out for haemorrhage, and allaying the excessive thirst, as much as possible, by rinsing out the mouth with hot so- da-water or plain water and moistening the lips from time to time. As a rule, the patient is not allowed to drink water, as it induces and prolongs nausea, which would defeat our main object, which is to keep her in every way as quiet as possible. Even ice should not be given as it only increases the thirst and nausea. If the thirst persists, a high enema consisting of a pint (500 cc.) of normal salt solution may be administered slowly, and repeated if necessary. Nourishment by the
AFTER -CAKE
407
mouth may not be ordered until after twenty-four or thirty-six hours, and then probably only in very gradu- ally increasing quantities. Small quantities of al- bumen water — two teaspoon fu Is every two hours — are generally well borne, or a little milk and lime-water may he tried. Half an ounce of champagne with cracked ice is sometimes very grateful. Stimulants should be kept near at hand, and if the patient is in an exhausted condition, a nutritive enema may be ordered at once, so that the necessary articles for giv- ing one should be ready for use at a moment's notice. Unless the patient voids urine within eight hours after the operation, the retention should be reported and a catheter prepared. If urine is voided, the quantity should be carefully noted. The bowels will nearly always need attention by the morning of the second day, and it is important that the nurse should record and report accurately the result of the enema which is generally ordered. If there be no result after several repetitions, she should be particular to report the fact immediately, as failure on the part of the bowels to move may indicate an obstruction, and the surgeon may wish to institute further treatment at once. For the first week or ten days a neat and accurate record sheet should be kept by the nurse. The pulse and temperature arc carefully watched and any changes are to be promptly reported. For uneasiness and pain in the back, small flat pillows and the knec-pad must be adjusted and changed whenever necessary. To case distress caused by the continuous dorsal position, when twenty-four hours have passed after the opera- tion, at intervals the patient may be carefully turned
4i I
NURSING
hi i h.r side for a few minutes, the tack being support- il with pillows.
i nleu Otherwise specified by the doctor, the diet ihoukl consist of liquids until after the sixth day or iiiuil the stitches are removed, when soft food may gradually be added. At the end of twelve days or a fortnight a general diet is ordered. The patient is al- lowed to sit up in bed from the twelfth to the eighteenth day, and is able to go home at the end of the third or the fourth week. As a matter of comfort an abdominal bandage is fitted on her before she is allowed to get out of bed.
The After-care of a Case of Perineorrhaphy.
For the first twenty-four hours the treatment is practically the same as for cases of abdominal section, but soft food is generally ordered on the second day, and the bowels should move freely at least once daily ; an enema should be given previous to the movement, to soften it rod fo prevent straining. When a patient is having a movement of the bowels, great care must be taken that the stitches are not torn apart, and if there be any straining whatever, die nurse should hold the parts together: this is a good plan to follow, at any rate fur the firtt few day*.. Usually catheterization is Ordered during the first forty-eight hours. Aseptic precautions must be carefully observed, the parts should be bathed before using the catheter, and the greatest care employed to prevent any drops of urine from falling upon the stitches; the wound should be washed off with a little sterilized cotton held with the forceps and dipped in a saturated solution of boric acid. It should then be wiped gently and Quite dry with bits
AFTER-CARE
409
of cotton held in the same way. and powdered boric acid or other powder, or the dry dressing ordered, re- applied. The hands should be scrubbed clean and di> infected before beginning the work. These precautions should be taken , arli time the urine is voided and after every movement of the bowels. Extra safety can be assured by the use of rubber gloves that have been soaking in a 1:1000 bichloride JOlution. Usuall;, ;i little gauze packing is put just within the vagina at the time of the operation to absorb any oozing from the pitches, and this should be removed the next morn- ing. A douche ihould never Ik- given after incorrhaphy without an order from the surgeon, and the greatest care should be taken to see that no water is left lying against the stitches within the vagina, as is to happen unless one swabs it out and maki - the surfaces quite dry, which ma, be dOM with the aid of forceps covered with cotton. After an operation upon the pcrinxum the patient should be kept in the recum- bent position fur tin- first ten hours. After this, if she is restless and complains of pain in the back or if she de- sires to change her position, she may be carefully turned on her side. A small soft pillow should be placed between the knees; a bandage around them will seldom be necessary.
Hwmorrhage is liable to occur after operations upon the cervix or after a perineorrhaphy, and the nurse should he able to control it until the doctor arrives. For bleeding from the cervix a hot alum douche is generally all that is necessary, but if this is not effect- ual, the vagina should be cleaned out with cotton ap- plied by means of the forceps, and tightly packed with plain sterilized gauze or gauze medicated with some
4io
NUKS/NC
such astringent as tannic acid in powder or solution. For hemorrhage from the perineum, the parts may be elevated and pressure made with a pad of cotton or gauze against the bleeding surface.
Lavage of the bladder in gynaecological cases is usually ordered for a cystitis which may be cither acute or chronic. Boric-acid solution is most frequently used. This is sometimes mixed with an equal quantity of salt solution. Three pints should be used ; the urine is first drawn off and then a pint of the boric-acid solution allowed to run gently in ; half the fluid is drawn off, the tube replaced, and the other pint, if necessary, is introduced. The third time this i$ done the water should be clear when emptied from the bladder. Another favorite solution for irrigating the bladder is Thomas' fluid, made as follows: Normal salt solution, i litre; borax, 15 grammes; glycerin, 20 cc.
Some patients cannot bear so great a distention of the bladder, and as soon as any complaint is made one should allow the fluid to escape. The vessel and catheter used must be surgically clean, and all precau- tions taken as in an ordinary catheterization.
As nurses arc constantly hearing difficult and un- familiar words used in connection with gynaecological work, and as it is important that they should in many- cases understand something of the nature of the opera- tion performed, a synopsis of gynaecological opera- tions and the terms applied to them will be introduced here :
Metritis. From the Greek metra, uterus, the termination itis, signifying inflammation. Inflamma- tion of the uterus. This condition may be due to any
CYNAiCOI. OUICAL TERMS
411
inflammatory condition existing in the pelvis; more commonly it comes on as a consequence of post-partum infection (after labor), and is known as septic metritis.
Endometritis. From the Greek endon (or endo), meaning within, and metritis, inflammation of the litems ; inflammation of the Using membrane of the uterus. For this the operation of curettement or curet- ting is performed, which means the removal of the in- flammatory products by means of a dull or sharp curette.
Stenosis of the Os Uteri or Cervical Canal. {Sten- osis, a narrowing; os, mouth). A contraction or nar- rowing of the cervical canal. For this the operation id dilaiing is performed, which means the stretch- ing or dilating of the cervical canal by the use of in- struments called dilators, or of sponge tents.
Laceration of the Cervix Uteri. A tear of the neck of the womb. The tear may be unilateral — 1. e., con- fined to one side; bilateral — taking in both sides; or stellate — irregular or star-shaped. This condition is generally caused by childbcaring. For this lesion the operation of trachelorrhaphy ( from the Greek trachc- los, neck, and rhaphia, a sewing) is performed, in which the torn lips of the womb are brought together by sutures. When this is done immediately following childbirth, it is called the "immediate operation ;" performed after the first weok. it is called the "second- ary operation."
Relaxed Vaginal Qutlet. The relaxation of the tis- sues that form the entrance to the vagina. This is caused by over-distension of the parts during child- birth. The operation performed for this is known as perineorrhaphy {perineum, and rhaphia, a sewing or
412
NUKSIXG
suturing), and has for its object the bringing together of the relaxed tissues by dissecting away a portion of the mucous membrane of tin: vagina, and then uniting the denuded parts by sutures.
Laceration of the Perineum. A tearing of the tis- sues forming the perineum. There are several grades. When the laceration extends through the sphincter ani, it is known as a complete laceration : when it does not extend so deep, it is known as an incomplete or partial laceration. The operation performed for rem- ■ 'lying this condition is also known as perineorrhaphy, and, as the name implies, means the bringing together of the parts by sutures. In cases of complete lacera- tion special care must be used in giving encmata. for some time after the operation, to do it in such a way as to avoid disturbing those sutures which have been passed through the fibres of the sphincter ani.
Excision of a Bartholinian Cyst. The cutting out of a cyst formed by dilatation of the duct coming from one of the glands of Bartholini. The gland becomes swollen as the result of the accumulation of its secre- tions due to the closure of some portion of the duct.
Uterine and Cenical Polypi. These arc rumors which occur in the mucous membrane, and are made up of the same kind of tissues as the membrane from which they grow. They are generally attached to some portion of the cervical canal or fundus of the uterus by a long pedicle or root. They arc removed by being twisted off with forceps, by excision, or by ligature and excision, by means of the cautery (Paquclin's), or the (craseur.
Carcinoma of the Cen-ix Uteri. Cancer of the neck of the womb. Its most prominent symptom in the
GYNAECOLOGICAL TERMS
4»3
majority of cases is hemorrhage. The treatment of this condition is cither palliative or radical. By pal- liative treatment is understood the removal of as much as possible of the cancerous mass by means of the finger and curette, and the destruction of the tissue, which it is impossible to remove by this procedure, with the thermocautery. By the radical treat- ment is meant the total extirpation of the cancer- ous tissues. This is performed either by amputating the diseased portion or by completely removing the cervix and uterus by performing a vaginal hysterecto- my (from the Greek hystera, the uterus, and ectomia, cutting out).
Cystocelc (from the Greek cyslis, bladder, and celt, a tumor). A prolapse of the anterior vaginal wall, which brings down with it the bladder.
Colpocele. Gr. colpos, vagina, and cele, tumor. De- scent of the vaginal wall. Every cystoccle is a colpo- cele. The condition is frequently a consequence of labor. The operation performed for its relief is known as anterior colporrhaphy (colpos, vagina, and rhaphio. a suturing), which means the bringing together of the relaxed vaginal tissues by sutures.
Rectocele. A mixed word from the Latin rectum and the Greek celt, tumor. A prolapsus or relaxation of the posterior wall of the vagina, which brings with it the rectum. This occurs in most instances as a consequence of childbirth.
Amputation of the Cennx Uteri. The removal of the cervix. This is performed for prolapsus of the utenis ; also, for hypertrophic elongation of the cervix, or for cancer of the cervix.
4'4
NUJcSING
Pelvic and Abdominal Operations and Diseases.
Celiotomy or Laparotomy (the latter from the Greek lapara, lit. the flank, and tomia, a cutting), and Abdominal Section are synonymous terms employed to describe the incision through the abdominal walls.
Celiotomy is the proper scientific term, coelia being the' Greek for the abdomen, and tomia, meaning "cut-
ttag."
Ovaritis. Ovarium, ovary, itis, inflammation of. In- flammation of the ovary.
Salpingitis. Salpinx, the tube, and itis, inflamma- tion of. Inflammation of the Fallopian tube.
Salpingitis and Ovaritis. Inflammation of the Fal- lopian tube and ovary.
Abscess of the Ovary. A purulent collection (pus) in the ovary.
Pyosalpinx. Greek pyon, pus, salpinx, the Fallopian tube. A collection of pus in the Fallopian tube.
Hydrosalpinx. Hydrops, dropsy, salpinx, Fall' : tube. A collection of watery fluid in the Fallopian tube; dropsv of the Fallopian tube.
Haewatosalpinx. Haemo (gen. haematos), Wood, salpinx, Fallopian tube. A collection of blood in the Fallopian tube (most frequently due to ectopic gesta- ■
Ova- tan < ystomo, A cyst of the ovary.
Hacmaloma of the Ovary. A Wood-tumor of the
Dermoid Cyst of the Ovary A cystic tumor con- taining skin, teeth \ Dermoid cysts are con- genital tumors.
GYNECOLOGICAL T&KMS
4'5
Ovariotomy. Ovarium, ovary, lomia. section. Re- moval of an ovarv.
Oophorectomy. Ooplwrum. ovary, ectomia. ex- cision. A better term to signify an operation for the removal of an ovary.
Salpingo-obphorectomy. Salpinx, the Fallopian tube, odphorum, ovary, cctomiii. exdskxi. Removal of the Fallopian tube and ovary (as for myoma of the uterus). When the tubes and o%aries on both sides are removed, the operation in called a double salpingo- oophorectomy.
Myomectomy. Myoma, lit. a thing made of muscle, a muscular tumor; eclomia, excision. The removal of a myoma from the uterus. Such a growth is com- monly spoken of as a fibroid tumor, but myoma is the more correct term.
Hysterectomy, llystera, the uterus, ectomia, ex- cision. The complete removal or extirpation of the uterus. This may l><- dOM <iilicr through tin- vagina (vaginal hysterectomy) or through an incision in the abdomen (abdominal hysterectomy). It is generally performed for carcinoma (cancer) of the cen •': uterus.
11 ystero-myomectomy. The removal or extirpation of die uterus for myoma.
Uystcronhaphy or Supensio Uteri. Hystera, the Uterus, rhaphia, a suturing. The suspension of the uterus to the anterior abdominal wall by sutures.
Parovarian Cyst. A cyst developing from the par- ovarium of the broad ligament (between the ovary and
Fallopian tube).
Ectopic Gestation. A pregnancy going on outside of (he uterine cavity, generally in some portion of the
416
NURSING
Fallopian tube, in which case it is called "tubal preg- nancy." It may also occur in the ovary or even in the abdominal cavity.
Caesarean Section. The removal of the foetus from the uterus by means of an incision through the abdom- inal and uterine walls of the mother. It is resorted to only when the pelvis is deformed, or when the foetus is still living after the death of the mother.
CHAPTER XXIII. The Administration of Anesthetics.
A nurse is often called upon in private practice to administer an anxsthctic, as it is not possible at every operation to have sufficient medical assistance. She i-;m never feel herself competent to do this unless she has taken advantage of her opportunities in the hos- pital for watching and herself practising the adminis- tration, and for informing herself thoroughly of the principles and methods involved, of the dangers to be watched for, and of the proper way to guard against them. Every time she is present when a patient is being anxsthctized gives her another opportunity for following each step in the process, and when a fitting occasion for asking questions regarding any point pre- sents itself, she should not neglect it.
Anaesthesia means a condition in which there is an absence of sensation. The agents used to produce this condition ar<- called anxsthetics, and may be cither local or general in their effects. The general e£fed is produced by inhaling the anxsthctic in the form of a vapor or gu into the lungs, whence it is carried by the blood to the nerve-centres, upon which it acts.
Local anxsthesia is produced cither by the injection of the proper agents in liquid form into the subcutan- eous tissues or by applying them externally.
Anxsthetics arc largely employed in surgery, their principal uses being to do away with pain during opcra-
97 417
418
\UXS/.\<7
tions and to produce insensibility and a relaxed con- dition of the muscles when a thorough cxaminat: necessary. In obstetrics the inhalation of chloroform or ether is a great boon, and in medical treatment an- aesthetics arc sometimes given to control convulsions. Tlic general effect of an anxsthctic may be either par- tial or complete. The two substances most frequently used for inhalation arc ether and chloroform. In dent- istry nitrous oxide or laughing gas is used, as its effects pass off rapidly and the patient need not be put in the recumbent posture. For use as an anaesthetic it is liquified by pressure and stored in iron cylinders from which, at the room temperature, it is liberated as a gas. Xow-a-days pre- liminary inhalations of nitrous oxide are often given in order that the unpleasant first and second stages associated with ether and chloroform narcosis may be avoided and in this way the nervous strain upon the patient may be lessened. Profound anresthesia is pro- duced anally in from three to four minutes; a smaller amount of the other anxsthctic is required to keep up the effect, and the vomiting during and after narcosis is apt to be less troublesome.
To Prepare a Patient for Anaesthesia. — No solid food should be allowed for six hours previous to miration of an anxsthctic, hut a little water j cup of beef-tea may he taken three hour> before. If an anxsthctic is given very soon after a hearty meal, vomiting almost invariably follows, and may delay the operation; moreover, there is danger of solid portion of food being drawn into the trachea ami producing suffocation; or the throat and pharynx may become
ANAESTHESIA
419
filled up and the resulting obstruction prove very dangerous.
If the patient be very weak and delicate, the phy- lidaO may order a hypodermic injection of strychnin, tir atrophiu with murphin. di pi ndtng upon the patient's condition, before the administration of the anaesthetic.
The forenoon is the best lime to select for giving an anesthetic, as the vital powers :n< in better eemdition, if the patient has had a good night and is not exhausted by nervous excitement or pain. The clothing should be light and warm, but loose about the neck and chest, and no corset or tight wai>t should be permitted be- cause the respiratory organs must have freedom of movement. Tin urifM should be voided or the catheter passed. If there arc false teeth, they should be re- moved. If the patient be a child, care should lie taken to sec that the mouth is quite empty, as there may be coins, buttons, or other articles flowed away therein. The patient is placed in a recumbent position, with the head low or resting on a small air-pillow, and should be covered with warm blankets, the hands being left free, so that the pulse may be easily reached ; a towel is to be laid across the chcM under the chin. An extra towel and basin should be ready. The nurse must also have at hand a hypodermic syringe (steril- ized and in good order I, whiskey or brandy, tincture of digitalis, I Solution of strychnin, morphin, atropin, and aqua ammonia, as any of them may lie called for. There should be, besides, a liberal supply of chloroform iii- 1 I'ther, towels, inhalers, tongue forceps, wooden wedges or gags, and vaseline; the last is applied about the lips and nose to prevent irritation from the vapor. The pulse should be taken before starting.
420 NUX&tNG
The anaesthetic may be given to the patient cither in bed, after which she will have to be carried to the oper- ating-room, or in a room near the latter where there will be nothing suggestive of the operation. The room should be quiet, and no talking is to be done beyond what is absolutely necessary, and that in a low tone ; otherwise it takes longer to get the patient under the influence of the anxsthctic. Besides the ilietizcr. if the patient is a woman, the nurse should always be present to give any necessary assistance, but a second or even a third person may be needed if there be much struggling. Ether is probably given in this country oftener than any other anaesthetic, as there seems to be little danger to life under ordinary circumstances when it is carefully administered. The contraindications to the use of ether arc chronic dis- eases of the bronchi and of the kidneys. Speaking generally, chloroform is preferable for very young or very old patients.
If lights are used near the ether, they should be kept above the neighborhood of the can or inhaler, as ether vapor is heavier than air and very inflammable.
There are various styles of ether-inhalers, but one that is easily made and can always be had fresh and clean is the so-called "ether cone." It is prepared by I tiding one or two layers of paper or blotting paper — newspaper answers the purpose — together to make a thin pad about 16 inches long and 9 wide; this is cov- ered with oiled muslin and over all is stitched a small, loosely-made crash towel or a piece of linen large enough to cover it entirely : tin- whole is then twisted into the shape of a cone and held in place with pins, a small opening being left at the top. A small sea-
■
ETHEK
421
sponge or some absorbent cotton is put' inside upon which to pour the ether.
About half an ounce of ether is poured upon the sponge II first, and the cone held at a short distance from the patient's face, or for a few moments he may be permitted to hold it himself if inclined to be nerv- ous or to think that he is going to be suffocated. A fur these first few moments, however, when the feeling of irritation has passed, the cone should be gradually held more closely over the mouth and nose, very small quantities of ether being added frequently. The first stage is the most disagreeable, owing to the irritation produced on the mucous membrane of the mouth, throat, and bronchi, which may give rise to coughing and a sensation of suffocation. When the patient struggles, talks, or cries out, the pulse and respiration are quickened and the face flushes. The ether is kept up steadily, a few drachms being added from time to time, until finally the patient quiets down, the muscles become relaxed, and sensation is lost ; this stage is called that of primary anaesthesia. This, however, is only transient, and may in its turn be followed by struggling and excitement, after which there ensues a condition of complete anaesthesia in which there is absolute relaxation of the muscular system, the con- junctival reflex is abolished, the face and skin are moist, and the patient lies as if in a deep sleep. The pulse is full and quickened and the respirations are slow and regular; these, as well as the reflexes, should be watched constantly. The reflex to light should re- main active ; that is, when the eyelid is opened the pupil should contract. \ rapidly-dilating pupil i$ a sign of imminent danger. The time required to pro-
4J2
XUXS/SG
dace complete anaesthesia differs with .Efferent riduals, and nay vary from fire to twenty minutes, (t i» also modified by sex and age, women and chil- dren being influenced more readily than men. Patients who have been alcohol habitues usually struggle vio- lently i during the straggling the anaesthetic most be pushed, but great care must be taken when the strug- gling begins to cease, as the patient then passes with great rapidity into the stage of complete anaesthesia.
In the early stages of the administration of ether the patient may suddenly stop breathing and the face be- come cyanoscd ; the cone should be at once removed, and pressure made upon the chest and sides once or twice, when the breathing will recommence. After the patient is ready for operation, the etherizer continues to keep a constant watch upon the pulse, respira- tion, reflexes, and general condition, and a few drops of ether in the cone from time to time will suf- fice to maintain the unconsciousness. To prevent the tongue from failing back into the throat and thus obstructing the air passages, the lower jaw should be pushed forward and upward. It may be held in this position by two or three fingers placed behind the angle of the jaw. while the others keep tlie cone in '•. Any accumulation of mucus in the mouth should fr'im time to time be wiped out with a tow. I. and the patient's head should lie turned to one side to allow as much as possible to escape in this way. If we arc warned by contractions of tin inal
muscles (retching) that vomiting is threatening it may lie averted by pushing the ether: if the patient vomits, the head is to Ik- quickly turned to one side, and the mouth cleaned out before an inspiration can be taken,
CHLOROFORM
4*3
otherwise some of the solid particles vomited may be drawn into the larynx. If the breathing ceases, the head and chest should be lowered to send more blood to the brain, and artificial respiration should be be- gun at once and maintained until breathing is reestab- lished : aqua ammonia may !"■ held at a tittle distance from the nostrils. The pulse may be conveniently counted in the temporal or in the facial artery and
if 'i grows weak and fluttering, me attention of the
surgeon should be at once called to the condition. Ether is very irritating to the kidneys, and the amount of urine should In- accurately measured for some days before and after the administration.
A patient should be watched until consciousness Is restored, which usually takes place within half an I mm or an hour: with some the effects arc slept off. while Othen may be very excitable and hysterical. Nan and vomiting frequently follow ether narcosis, and basins and towels should be kq>t at hand, so that the clothing may be protected. The head must be kept low. no pillow being used. If the vomiting is per- sistent, frequent drinks of water only aggravate it; Seltzer water in sips or a little cracked ice is better. The extreme thirst may be somewhat relieved by hot tea or hot water, a teaspoon ful at a time. If there be pain from accumulation of gas, a drop of the tincture of capsicum in a little hot water will often give I For headache an ice-cap or ice-cloths may be applied and the patient kept quiet ; no visitors should be allowed.
Chloroform ranks next to ether as a systemic anaes- thetic. It has some advantages over ether, as it is more pleasant to take, its vapor i» not so irritating to
4*4
S'URSfXG
the muccnu memlrranc* of the mouth and throat, an it» action is much more rapid, while its after effects are 1cm disagreeable. On the other hand the danger to life where the administrator has not had a wide experience is much greater than with ether, as it acts at once upon the respiration and depresses the heart. Children and old people bear it better than the middle- aged. To prepare a patient to inhale chloroform the same points are observed as with ether: anointing the lips and nose with vaseline or ointment is here even more essentia], as chloroform vapor is very irritating, and if applied to the skin for any length of time may produce vesication.
■rm-inhalers are of many kinds: the small wire frame covered with flannel is perhaps among the simplest and best, but in the absence of any special apparatus a towel or napkin may be used. Half a drachm of chloroform is poured upon the towel, which at first is held some little distance from the face, and gradually brought nearer until it is within two or three inches of the nose and mouth ; this allows for free dilu- tion with air — an absolute necessity. The patient ibotlld 1* induced to breathe quietly and gentl;. in order to KVOid U) irritation or sense of suffocation; ih. lime required to produce insensibility is about five minutes, and when this is complete there will be no contraction of the eyelids when the conjunctiva is touched The pulse, respiration, pupil, and color of the face should be constantly watched, as, while the t is in apparently good condition, the breathing or the pulse may suddenly cease and the face take on a livid hue or heconic ghastly pale. These are indica- tions of danger, as death may quickly follow from
/ OCA!. ANAESTHETICS
4*5
paralysis of the heart and respiration. Artificial res- piration is at once resorted to if the respiration ceases. If it be the pulse that stops, no time must be lost, and the patient must be partially suspended with the head lowered, and artificial respiration at once instituted. A nurse will probably seldom, if ever, be entrusted
with the administration of chloroform.
Chloroform is used almost exclusively instead of ether with obstetrical patients; it is administered generally during labor in the second stage when the pain is very severe or when forceps are applied.
The agents used as local anaesihetics are the hydro- chlorate of cocain, ethyl chloride, carbolic acid, alco- hol, and ice.
Cocain is a powerful local anaesthetic ; it is used in solution in strengths from i to 20 per cent. Fot the surface of mucous membranes a piece of cotton saturated with the solution [| applied to the area fur a few minutes until insensibility is produced. It is also largely used hypodcrmically, sometimes being inject- ed into the nerve trunk supplying the part. Before injections are given the skin and syringe should be antiscptically prepared. Cocain is particularly valu- able in operations upon the eye, ear, throat, ami nose. as well as in making examinations of these organs: it should never be used, however, except by a phy- sician's order, as individual susceptibility to the toxic influence of the drug is sometimes marked, and death has more than once been caused even by weak solu- tions. Some surgeons prefer using a weak solution of cocain combined with Carbolic acid: so it is well to have l>otli drugs in readiness.
To produce insensibility of a part by means of car-
4*6
UUBS/S'C
bofic acid, the pore acid f Inpirfitu) is tunned orer toe •kin ; it at first cause* ww pain, which, however. is fonontd by nirrahness. when an inriwno tnaj be without its wing Ml 'Jwmg to as cansm upon the tissues, the drug is rarely cuptojed for porpose.
If a vessel containing alcohol is placed in a larger one which has been filled with ice and salt, the alcohol it rendered very cold. If now the part (a finger or hand) i» placed in it or compresses kept very cold with the alcohol are applied to the surface sensation soon become* benumbed. Ice and salt held in contact with the t -o which the incision is to be made
will al»o rcn'lcr them less sensitive to pain.
A spray of cth\l chloride or ether directed upon the surface for a few seconds will also bring about a COIKJ local anesthesia.
CHAPTER XXIV.
Infectious Diseases. — Fever. — Typhoid Fever.— Macarial Fever. — Scarlet Fever. — Dysentery. — Asiatic CSOUU, -Small- Pox.— Dii'htueria.— Pulmonary Tuberculosis.
Fever is present in almost all acute infections : it is not a disease in itself, but a symptom. The progros of a disease may oftentimes be estimated and indi- cations for treatment may often be obtained by watch- ing the course of the fever. For several of the Infec tious diseases the specific euuafivc germs have been demonstrated, while in the case of others, although these also arc supposedly referable to a germ origin, positive proof is still lacking. There are certain con- stitutional symptoms that arc generally found in any condition of fever. Beside-' the increase of the hod\ heat and the pulse rate, headache and backache, vary- ing in kind and degree, chilly seiwitioni or severe rigors, great thirst, dryness of the in.nitli, tongue and throat, loss of appetite, impaired digestion and sleep- lessness, are often met with. In all fevers, as a rule, there are three more or less well marked stages (l) that of invasion — while the temperature increases : (2) the stage of acme when the disease reaches its height : (3) the stage of decline or defervescence. In all febrile -es there is waste of the body-tissues, and this is usually proportionate to the hejgbl and duration oi the fever. In caring fOf fever cases one should ar- 1 for absolute and and body ; any exertion
«7
42K
.VUKS/XG
produces not only an elevation of the temperature, but also an increase in the pulse-rate, and thus adds un- necessarily to (he tissue-waste, while at tlxr same time it increases the strain upon the heart. The patient should be made as comfortable as possible ; there should be a constant supply of fresh air; the bed must be carefully looked after, and always kept fresh ; all heavy clothing should be avoided : a night- gown which opens all the way in the front for the patient, and a sheet and a light blanket for the bed, will usually afford sufficient covering. If regular sponge-baths are not ordered to reduce tl>e tempera- ture, in any case a sponge-bath should be given every morning, and repeated at night if possible; if the patient is so sick that nothing more can be done, the face, hands, and back at least should be sponged. Frequent cleansing of the mouth is desirable, not only for comfort, but also to inhibit bacterial growth in it, and thus lessen the chances of a complicating inflammation of the parotid gland or middle ear, or a bronchopneumonia. The bodily strength should be kept up by the regular administration of nutritious food, given in liquid form, milk, as a rule, being the best. For the reduction of temperature medicinal agents or applications of cold water will prob- ably be ordered ; the latter method is the one most extensively used at present, the majority of physicians believing that antipyretic drugs produce too much prostration if continued through a long illness. When fever first appears it is always safer to isolate the patient until the nature of the disease has become manifest and thus avoid any risk of infecting others.
TYPNOfP FEVER
V-'.
These general directions apply to the management of fever when present in am disease. Wc shall now speak briefly of the infectious diseases, by which wc mean those resulting from an invasion of the body by micro oryimi ins. These may or may not be directly contagious. It is important that a nurse who has charge of several j ■ ; 1 1 1 • - r 1 1 -- houM be constantly on In r gUSlid against conveying infection from one to an- other. The strictest cleanliness in regard to vessels, hands and general surroundings is essential.
Typhoid fever is an acute infectious disease, caused by a microorganism (Kherth's bacillus) It is char- acterized by a fever running a definite course, with local inflammation and ulceration in the small intes- tines, particularly of the patches of Peyer. These Pcyer's patches are scattered throughout the mucous coat of the small intestines, being most numerous in the ileum ; the inflammation and ulceration may also ex- tend into the colon, in which case the solitary follicles are chiefly involved. Typhoid is most prevalent in the late summer and autumn months. The majority of cases occur in Individuals over fifteen and under forty years of age. The period of incubation btstt from one to two weeks, but wide variations arc met with ; the duration of the fever in moderate cases is about three weeks, convalescence beginning in tin- fourth week ; in protracted cases, however, con- valescence may be delayed until the seventh week.
The prodromal symptoms arc — constant headache night and day. aching of the limbs, ami a dull tired feeling, with chilly sensations, loss of appetite, and perhaps nose-bleed. There is usually a gradual and progressive rise of temperature, with morning and
XUKSIXG
evening variations, the evening temperature being higher on each successive day by a degree or a degree and a half, generally reaching 1030 or 1040 F. by the eighth day, where it remains with but slight variations during the second week. Then' is also but little difference between the night and morning temperature during this time, but in the third week there is a distinct fall in the morning and a gradual decline in the evening temperature. The pulse-rate increases proportionately with the temperature, going to 100 or 1 10 or even higher. The headache usually ceases about the tenth day. A bronchitis with a troublesome cough may be present from the beginning and continue throughout the attack. The rash appears from the seventh to the twelfth day in the shape of rose-colored spots seen on the abdomen and thighs, and sometimes on the back, which disappear on pres- sure and return when it is removed, each spot lasting about three days. They often appear in successive crops. The tongue at first is coated and white, but afterwards may be very dry, dark, and cracked if the sordes that accumulate rapidly arc allowed to dry upon it. The lips 111:1 v In- 111 i!u same onulition and become very sore. By "sordes" we mean the dark- brown accumuli which remain in the mouth, being a mixture of (cod, epithelium, and micro-organ- isms. They collect thickly on the tongue, teeth, and lips, but such collections can be prevented to a great extent by Frequent washing out of the mouth with antiseptic cleansing lotions and by giving the patient plenty of wnti r to drink, especially after he has taken milk or other food. The mouth is most casilv washed
TYPHOID FF.VER
43'
out with small squares of gauze or soft muslin, which after use are to be at once burned.
Constipation or diarrhoea may be present at first, the latter being more frequent, but an average of three or four stools a day during the second week is not un- common. These stools have a yellowish, pea-soup appearance. Their character should always be care- fully noted and if there be anything unusual about them, they should be kept for the phytic an - inspec- tion; if there be constipation, the bowels should be opened daily by an enema, which should not, how- ever, be given without the order of the physician. The care of the excreta has been described elsewhere. The characteristic odor of typhoid discharges is prone to cling about the patient unless scrupulous cleanli- ness in regard to the body and linen is observed. Its presence is always a sign of careless nursing. The urine is diminished in quantity at first, and retention should be watched for ; later the flow is more abundant.
Haemorrhage from the bowels may occur at any time after the second week. The first indication it ally a sudden fall of temperature with symptoms Of COl lapse, or the blood niav appear suddenly in tl The patient should be kept perfectly quiet on hJl back, the foot of the bedstead should !«• elevated, and an ice- bag applied to the abdomen. Ice may be given by mouth but for some hours little if any nourish the bed-pan should be adjusted with the least possibl disturbance to the patient. A sudden drop in tempera- ture from high fever to or even below the n< should be at once reported, as it may indicate cither haemorrhage or perforation. The li :. >m.
43*
NUftS/NG
from the sloughing through of the walls of a vessel at the base of an ulcer.
Perforation oj the intestine is one of the greatest dangers in the COOTM of typhoid fever. The wall of the intestine gives way, and through the hole, which is often very small, the contents escape into the peri- toneal cavity, giving rise to a peritonitis which gener- al I v ends fatally. The symptoms are those of collapse, accompanied by severe pain, with a sudden fall of temperature! a small rapid pulse, and distension of the abdomen. The knees are usually drawn up and the it looks desperately ill. In such instances, how- ever, prompt surgical interference has often saved life.
Tympanites. — Distension of tlte abdomen from gas in the intestines is frequently present, but is not con- sidered a serious symptom unless it is persistent and marked. If turpentine stupes arc ordered, care should he taken to have them well applied. Turpentine enemata are sometimes given for the same condition.
A reliifse may occur once, sometimes indeed even
two or three times, after convalescence has apparently
begun. Then too. besides a genuine relapse, there are
rally nuked elevations of temperature, lasting
■ few hours or days, due to errors in diet, ovcr-exer-
r excitement. The nurse must be careful about
and also avoid anything which might put too
sudden a strain on the enfeebled heart, as sometimes
death results from Heart paralysis.
For insomnia or other nervous symptoms the ice- cap may be ordered or iced cloths be applied to the head. Sometimes sponging will allay the restlessness. A delirious patient inclined to get out of bed should
TYPHOID FEVER
433
be watched constantly and never left alone. M;nr, lives have been lost because the nurse has thought that she could safely leave a patient for a few mo- ments. Any delusions must be met with tact and a true appreciation of the patient's condition. A certain amount of risk is always encountered by the nurse in cases of delirium, as a violent attack may be made with- out a moment's warning. Among the symptoms which arc considered unfavorable are marked muscu- lar twitchings, excessive tympanites, prolonged high temperature, and a lipid fall of temperature. A grad- ual fall of temperature, while the tongue becomes moist and clear about the edges, with return of ap- petite, is a symptom of approaching convali-M
The treatment, besides the measures employed for the reduction of the temperature, consists chiefly in good nursing. The temperature i- minced by the ap- plication of cold water, In humus of the tub-bath, spongings. or the cold pack, all of which procedures have been already descriln d in the chapter on "Baths." The bath is usually ordered if the temperature rises above 102.5° F.
Liquid or very soft diet is ordered while the tem- perature remains high. Where milk is the principal food, from three to four pints arc usually given in the twenty-four hours (from four to six ounces every two hours), being well diluted with cither plain or aerated water. Milk may be alternated with koumyss, chicken-broth, beef-tea. mutton-broth, albumen-water, or weak cocoa, and plenty of water should be given to drink, whether asked for or not. Wine, jelly, junket, icc-crcam, fruit-juices, strained lemonade, iced tea. or coffee may be given occasionally. The objection to
434
NURSMG
milk is that it forms hard curds ; some physicians ob- ject to its use altogether and order instead any soft nourishing food, such as is allowed after the fever has abated. One of the latest pluses of treatment is to give water to drink — all the patient can be made to take — every fifteen minutes. Whether or not a patient •hall be wakened for his nourishment at night is to be decided by the physician.
Soft food, in the form of eggs, milk-toast, custards, and jellies, is usually ordered when there is no fever in the evenings, but physicians do not. as a rule, allow any solid food until a week or ten days after the tem- perature has become normal, and then it is necessary to begin with small amounts. Milk or food of any kind should not be allowed to remain beside the patient or anywhere in the room. Especial care should be taken to disinfect the dishes used fur typhoid patients, and no milk or food of any kind intended for other patients should be allowed to come in contact in any way with a typhoid case, as the bacilli which cause the disease find in them suitable media for growth and de- velopment.
The ventilation of the room, the cleanliness of the I ii son and of his bed. the disinfection of the
linen and of the excreta (of the urine as well as the fires), regularity in diet, — all arc things to be very particular about in caring for a case of typhoid fever. The patient should be turned from side to side quently, and his back supported by a pillow. Be must be prevented, and any evidence of local niation or abscess at once reported. Signs indi- cative of other complications — meningitis, nephritis, pnermoma, phlebitis, otitis media, and heart exhaus-
_
MALARIAL FEVER
435
tion — should also be watched for. Pregnant women usually abort during typlio.l
Typhoid is probably contagious only through the urine, and fleets, bat nurses should always be careful tO disinfect their hands thoroughly after working over a patient, and especially before going to meals. Water is one great source of infection, and should be boiled I ir fore i' is used if there is any suspicion that it is contaminated. Massage is a great help in conva- lescence in overcoming emaciation and weakness ; it aids in establishing health more quickly.
Malarial fever is an infectious disease due to animal organisms that invade the blood and rapidly destrO] the red blood -corpuscles. It is characterized by an intermittent type of fever, a paroxysm occurring usually every day or every second, third, and much more rarely every fourth. There is also a rami type and a chronic type. The most frequent form is the intermittent, in which there are definite chills. Three distinct stages may lie observed: first, the cold stage, in which the patient has a chill of greater or ! Intensity, lasting from ten to fifteen minutes to mo« than an hour, during which time he suffers from intense headache, backache, sometimes nausea, and vomiting, the temperature rising npidlj ; in the second or hot stage the patient feels as though he were burn- ing up, the face is deeply Bushed, and the tempera- ture goes to 1050 F. or higher: after from three to five hours the temperature falls, and we have the third stage, in which there is profuse perspiration, the head- ache and other symptoms subsiding, and the pnii ui though weak, feels better. The attack may come on the next day (more often one day is missed) unless
436
NURSIXG
something is done to destroy the organisms in the blood. During the paroxysm the patient may be made more comfortable by hot bags to the trunk and feet. with nr. ice-cap to the bead; for the intense thirst aerated waters or lemonade may be given, the latter being particularly acceptable. A spongc-liath is often ordered to be given both during and after the fever, and when the patient has ceased to perspire the linen should be changed. If the infection persists, a condi- tion known as chronic malaria may be estab- lished, with development of a marked anarmia from decrease in the number of the red blood-corpuscles.
Quinine, best given in solution, but often also in capsules or wrapped in rice or tissue paper, is the specific remedy against malarial infection; from fifteen to ibirty grains daily for three days, given in divided doses, is the amount usually prescribed. Smaller doses arc then given for the next two or three weeks.
Scarlet Fever is also a contagious disease which has a stage of invasion, one of eruption, and a third of desquamation. The time of incubation is variable, being from four to seven days. The symptoms begin abruptly ; there may be slight indisposition for a day. that may be taken for the beginning of an ordinary cold, but the temperature increases, and very soon rises to 1020 or 104* F. ; a higher temperature than this indicates a grave condition. The pulse-rate in mild cases is from no to 120, but in severer cases it may reach 160 or more. There are usually head- ache, chilly sensations, nausea and vomiting, the tongue is coated, and there are more or less dryness, soreness and swelling of the throat.
The rash generally do-clops on the second day.
SCARLET FEVER
437
appearing first on the neck and cbttt in reddish Uld patches, which rxl. nd fiver the hack to the trunk. and finally over the whole body. The lips and chin usu- ally remain free. In mild forms the rash does BOl change in appearance, hut in marked cases it takes on a vivid scarlet color. The so-called "strawberry tongue." due t'i swelling of the papilla, now appears, the throat becomes red and swollen, and an exudate amy some- times be present closely resembling the false mem- brane of diphtheria. The duration is variable, de- pending upon the violence of the attack. In a typical case the rash gradually fades, and from the sixth to the k'Tith day desquamation begins, and il not com- pleted until the twelfth day or even later; often the peeling takes three weeks or more.
There arc various types of scarlet fever, from the mild form lasting a week or so, to the most serious kind, known as malignant scarlet fever, and which sometimes terminates fatally in two or three lays; in the latter form the temperature may be very high, 109° F. or more, the pulse rapid, the restlessness ex- treme. These symptoms may be followed by delirium and coma in which the patient dies. The throat - toms are sometimes pronounced, and in this form the appearance of a membranous exudate is not infrequent ; the rash is dark red. and may even be hemorrhagic. The patient must be completely isolated, and nothing should be left in the room in the way of furniture ex- cept articles which arc absolutely necessary. In the mildest forms the patient must be kept quiet and in bed until the end of the fourth week, as nephritis is very liable to follow even these cases. When the fever is high, sponge baths, tub-baths at a temperature of
438
NUKSIXG
8o° 1 Id pack* arc p-commendcd. The ice -cap
should be kept constantly applied in cases in n there is high fever. Milk and lime water and barley (rater are to be given freely. The taking of half a glass of water every hour during the day may be ucd for weeks. The return to solids must be carefully regulated; as little extra work as possible should be put upon the kidneys. Meat and broths liibited until all danger is past The physician will probably direct that the urine be examined daily for albumin, and a careful record should be made by the nurse of the total amount passed. The period of desquamation is considered the most highly contagious, and tn anil care
must be taken to prevent the scattering about of the flakes of *kin. When possible, they should be burned, and all linen should be put at once into disinfectants. Inunctions of oil night and morning should be given, the oil being well rubbed in all over the body. A warm-water bath should precede the inunction in the morning. Exposure to dampness anil cold should be guarded against more especially in this stage, as the skin is very sensitive, ami if the surface of the body is Chilled Kfld the action of the sweat-glands is checked, nephritis may follow. Any pufnncss of the eyelids llmbl should be watched for. The first signs which might suggest a nephritis should be rq>orted at once. If tlu- patient complains of a chill or a chilly feeling, if there be an increase in the temperature, or if pufn- ncss of the eyelids and Feet, or change* in the appear- ance of the urine be noted, the physician may order a saline cathartic, that the skin be kqrt active, that plenty of hot water be given t>> drink, and that high saline in-
DYSENTS&Y
439
jections and hot baths be administered to induce per- spiration. Particular care during convalescence should be taken in these respects, as the patient may feel so well that to him such precaution-, seem unite unnecessary, and if left to himself he is too often apt
to be Imprudent
The complications to be watched for and guarded against, besides the sore throat and nephritis, are in- iition of tin- middle ear, extending from the throat and often suppurating, sometimes resulting in deafness, arthritis, or Inflammation 'if the joints, heart affections, and convulsions. The best of sanitary con- ditions should be maintained, and the general system well nourished. The mouth and throat should be sprayed and cleaned. The patient is to be kept free from unusual excitement, and should be careful not to exert himself too soon. If infls of the middle
ear develops moist compresses or an ice-bag may give relief. After rupture or puncture of the drum lin- ear may be irrigated with a warm 4 per cent solution of boric acid, or with a ]/i per cent solution .if [ysol as often as the physician thinks is necessary. For glan- dular swellings hot fomentations or ice poultices may he ordered; for irritation, the skin may be sponged with bicarbonate of soda and water. Isolation should usually be maintained for front six t>> eight weeks.
Dysentery is a disease in which there arc freqi* mi stools containing mucus and blood, accompanied by
tenesmus The acute catarrhal form ii an Inflamma- tion of the large intestine caused by a specific bacillus. It may begin as a painless diarrheca, hut in a short time there arc griping pains and straining, tin Itooli consisting chiefly of mucus and blood. The range of
44
NURSING
the fever is usually not high ; in the beginning it may rise to 102* or 103*. There may be nausea, vomiting, and great thirst The duration of the disease is from four to twenty-one days. The amoebic or tropical fonn -if 'Usentery is characterized by the presence in the stools of an animal organism called the Amoeba colt. It is also met with outside the tropics ; the stools, as a rule, are frequent and have a characteristic odor, which may be rendered much less offensive by the use of permanganate of potassium as a deodorizer. The patient is to be kept warm and quiet in bed in all forms of dysentery, and liquid diet, usually milk, chick- en broth, barley water, whey, malted milk, mutton broth and albumen water, is ordered. If curds ap- pear in the stools, the amount of milk is to be lessened, or egg-albumen and beef-juice may be substituted. A flannel binder should be worn. Pain and tenderness are relieved by turpentine stupes or hot fomentations. If injections of quinine or other drugs into the colon are ordered, they should be given in large quantities, high up and very gently, the hips of the patient being elevated. Antiseptic precautions are to be taken with the tube and vessels after use. the patient must be kept scrupulously clean and his linen and the dis- charges must be sterilized. Cold applications to the anus sometimes relieve the tenesmus.
Asiatic Cholera. — From bacteriological studies of this infectious disease it has been found that it is due to a specific bacterium present in the evacuations from the bowels, and that it is probably contagious chiefly through the stools or by the contamination of water Used for drinking and household purposes. In conse- quence, rigid disinfection of the stools and of the
I
SMALL-POX
44'
linen is necessary, and only boiled water and well- cooked food should be taken when the disease prevails. The stools of cholera patients are at first yellowish In color, but soon change to the so-called "rice-water" stools: they are profuse and very frequent. Severe cramps and constant vomiting are generally associated with them, so that unless the disease is checked the patient soon falls into a condition of exhaustion and collapse. Hot applications may be made over the ab- domen and heat applied about the body; warm injec- tions of tannic acid have been used with some success, and subcutaneous injections of warm salt solution (4 grammes of salt to the litre) are recommended as valuable, in that they supply the loss of fluid from the blood and system consequent upon the profuse watery evacuations. Opium is usually given to control the pain, and plenty of ice-water to allay thirst. Kneading and hot baths .or the cramps arc sometimes ordered. There is no great danger in nursing a case of chofa rl if sufficient attention be given to the food one takes, ..iter one drinks and the disinfection of the hands. Very careful nur im. is necessary during the convales- cent stage and a restricted diet should be maintained for some time.
Small-pox, 01 i-anola. is one of the most virulent of diseases. The poison is present in the secretions and excretions, being given off chielly from the Itfflgl ind skin. The stage of incubation is from seven to four- teen days; the disease propel begins suddenly with chills, intense headache, severe pains in the back, and vomiting, the temperature rising rapidly to 103* or 1040 F., with " full, rapid pulse. On the third or fourth day the rash appears in the form of small red
442
NUR.
spots, showing itself first along the junction of the forehead and hair, whence it spreads to the mouth and OVCf tin' body. When the rash appears the tempera- ture falls, and the spots or papules gradually develop until the fourth day; they then become vesicular and about the sixth day pustular. With the suppuration the temperature again rises, and there is much swellir of tl>c skin about the pustules, with tension and pain, more particularly in the face. In the discrete form, where the pustules remain separated, the temperature in a short time and convalescence begins, the ig subsiding, and the pustules drying up and .^mating; in the confluent form, however, the pustules increase in size, run together, break down and form crusts over the surface of the skin, particu- larly of the face and hands, until about tin- third week, when the fever abates and the crusts gradually dry up and drop off, provided the patient has survived the at- tack. In the confluent form there is great thirst and often delirium ; the danger is greatest in such cases about the tenth or eleventh day, being in proportion to the intensity of the eruption. Broncho-pneumonia is a frequent complication. Other complications, in- flammation of the middle car, pleurisy, endocarditis and nephritis, arc sometimes met with.
In caring for a s:nall-pox patient strict isolation is tin- first thing; tin best hygienic measures should pre- vail, the air being fresh and kept at a temperature of 65* F. The patient should be lightly covered. To re- duce the fever cither cold sponging or tub-baths may be ordered. The food must be liquid (milk, gruels, eggs, wine), and water maj I" given freely. The Jiair should be closely cut and the face should be pro-
DIPHTHERIA
443
tccted by a mask made of lint dipped in hot or cold water or in a i«per-cent e&rbolic-add solution, and then covered with oiled silk. Winn the scales begin to form, to prevent them from scattering and to keep the crusts soft, vaseline or oil is applied and warm baths arc given daily. Dilute carbolic-acid solutions arc useful in counteracting the offensive odor. Par- ticular attention should be paid to the eyes, mouth, and throat, and all sponges or dressings used should be burned at once. If possible, the patient should be in a room with an open fire, which renders this burning a matter of little inconvenience. Isolation should be kept Up until the skin returns to it> normal condition. All persons, including the nurse, who come in con- tact with a case of small-pox, shout J be vaccinated im- mediately.
Diphtheria is an acute, infectious and highly con- tagious disease, the result of a specific germ which gives rise to a fibrinous exudate which may appear upon any mucous surface or wound, but most common- ly affects the mucous membrane in the throat, with severe general blood-poisoning. The germ attaches itself to the clothing, the bedding, and the room in
which thr patkm has lived, it is i tant, and
may be found months after on articles dial have been exposed to it. Hence care should U- tak.-n to destroy or thoroughly disinfect anything in the way of toys or books that may have been in the room of a diph- , theria patient:
The period of incubation is from two to seven days. The first symptoms arc a chilly sensation, headache, a general aching of the muscle*, some soren and swelling of the throat and great prostration. The
NUKStXC
membrane is first seen, as a rule, upon the tonsils, and becomes more or less extensive according to the se- verity of the case. At first it is of a graytih-whitc color, which afterward changes to a dull gray. The temperature ranges from 102' to 103* F.. bat mar be lower. The glands beneath the jaw are enlarged. In nasal diphtheria there is a thin purulent or blood', charge which causes sores in the nostrils and on the up- per lips. Hoarseness, a croupy cough, or noisy difficult inspiration may indicate extension to the larynx. The sick person is to be strictly isolated and his clothing and surroundings disinfected. Other children in the house are to be carefully watched, given prophylactic gargles or even injections of antitoxin. The tempera- ture of the room should be about 68* and thorough ventilation should be secured. The air may be kept moist by means of a steam-kettle, or a screen may be arranged about the bed so that the child may breathe an atmosphere saturated with moisture. Local ap- plications, hot or cold, arc made to the throat, and everything is done to keep up the patient's strength, in order that he may be able to resist the effects of the poison on the system. Plenty of water to drink may be given. The food should be liquid, milk, becf-jutee, lirlv- water, albumen-water and soups. Where there is difficulty in swallowing, on account of obstruction Ud pain in the throat, nutritive enemata should be used. In laryngeal cases, intubation is resorted to early in the disease rather than as a last hope. The tube is passed Into the larynx, and feeding is done by means of a rubber tube passed into the oesophagus through either the mouth or nose. Where artificial feeding is not used, the head should be lowered and the milk be
Dll'HTHEklA
445
poured slowly and in very small quantities down the throat. In diphtheritic paralysis, if swallowing becomes very difficult, the patient may he fed with a stomach tube in preference to recta! feeding, General prostra- tion may be very marked toward the end of the at- tack. Stimulants are often ordered from the beginning. As the disease is very contagious, a nurse in swabbing out the throat should be careful not to beconu infected herself bs any discharge that may be expelled during coughing or when she is applying the disinfectants. The expectoration should be received in small squares Of muslin and at once burned. The strictest quaraa tine should be established, and only the nurse, doctor, and ]")• il>l'. the child's mother, be allowed to come mar the patient. The bed-linen, dishes, and room should undergo the most rigid disinfection before being again put into general use.
Temporary paralysis is not infrequently a sequel of diphtheria; it may come on as late as a month 01 tut weeks after convak i a • It may be local, affi only the muscles of the throat and palate, or it may be more general, and include the muscles of the limbs, The eye-muscles, too, are often paralyzed. The nurse will, therefore, be on the witch for signs of speech, regurgitation of fluids through tin nose, 01 in ability to focus the eyes on near objects. Heart failure may occur even after convalescence hascommenced.and any undue exertion should he avoided. A nurse >ln>nld he more than ordinarily careful of her own health while taking care of a case of diphtheria, and it is a good plan to use preventive treatment bs gargling the throat and possibly taking a tonic; the physician will no doubt sec to this where the nunc has but little
446
XURSfNG
sleep or opportunity for daily change of air. Im- munity to diphlhct be established by means of injections of the diphtheria antitoxin. In favorable cases the effects of the scrum arc seen in the marked uneUontioa of the local and the general symptoms. Within twenty-four hours the swelling of the fauces subsides and the membrane begins to disappear. At the same time the temperature falls, the pulse become* stronger and the general condition of the patient im- proves in every way. The earlier the cases come under treatment the better arc the results. Among the un- toward effects of the treatment which arc occasionally met with, is the development of a local abscess, diffuse erythema, urticaria, and albuminuria. None of these arc. however, serious. Since the ose of the antitoxin tlu- mortality from this disease has been greatly re- duced. The <kwe of the scrum varies according to the severity of the case, but as it is harmless it is al- ways safer to give relatively large amounts. The in- jections are made most commonly into the loose tissues between the shoulder blades or into the buttocks. Isolation should be maintained until the cultures from the throat have proved negative for three successive thy*.
Pulmonary tuberculosis. After all that has been written on the subject, thousands of valuable hres are lost every year because people will not under- stand that one case of tuberculosis can be the cause of many others, and that the disease, which is com- monly called "consumption." could, with proper pre- cautions, be almost entirely stamped out.
The disease may be either acute or chronic. In the acute form in the early stages there is consolidation of
TV/1KKCU/.OS/S
447
the lung, and later softening or excavation, winch fol- lows the liquefaction of the necrotic tissue.
The bacilli enter through the air -passages and lodge at some point on the respiratory surfaces. The most frequent starting-place is at the termination of a bronchiole, just before it Opens into the lung alveoli. The apex of one lung is most often first attacked. The symptoms are a dry, hacking cough, with gradual but steady emaciation and loss of weight . there ma,\ be sharp pain in the side, with a rapid and feeble pulse, the temperature being normal or subnormal in the morning and elevated in the evening When cavities form, there may be occasional chills, and profuse sweating may occur, especially when the patient is asleep. The expectoration is opique, mucopurulent, and contains tubercle bacilli, and in the later stages elastic tissue; it may lie glairy, tenacious, an<l streaked with blood, and will become more profuse when the breaking down of the lung tissue has begun ; there may be nausea, vomiting, and diarrhoea, particularly late in the disease. The skin has a pearly pallor, the hectic flush appears on the checks, and the eyes arc bright and glistening. Hemoptysis is sometimes the very first symptom, and it may occur at intervals throughout the disease. The acute form is generally rapidly fatal, but if taken in the early stages may lie curable.
Life in the open air and a Superabundance of nour- ishment even to the point of forced feeding is the treatment now insisted upon, the object being to in- \w patient's resistance to the highest point. Absolute rules as regards rest arc laid down by the physician for each individn.-d patient! generally speak-
448
NUKSIMG
ing an hour's absolute rest just before and after each meal, a daily bath, a certain amount of walking in the open air if the patient has no fever, and sleeping with windows wide open or entirely in the open air, with a set amount of nourishment suited to the individual
arc insisted upon. The temperature should watched carefully and taken at least twice daily ; the mouth and teeili should K vive particular attention ; the patient should be weighed once a week. Since the prospects depend in a large measure upon the cood$> lion of the stomach, foods which are too rich and heavy should be avoided. The did should be mixed and va- ried. Meat, eggs, vegetables, cereals, fish, fruit, tro- pon, plasmon and sanatogen. arc all good. Milk, to the extent of two or three pints or more daily, shouk be given ; if necessary a little tea, coffee, salt or brandy may be added to it. Some patients prefer sour milk, cream or kmimyss. The best means of isola- tion are afforded by sanitaria and special hospitals for tuberculosis. The tent system— for winter as well as mer — is growing in favor.
In the chronic form the progress of the disease may sometimes be arrested. The treatment consists prin- cipally of hygienic measures. Warm flannels, good nutritious diet, a great ileal of outdoor life and plete rest — all arc valuable ; later, gentle exercise may Knitted, when the patient has no fever and car stand it without suffering from over-fatigue ; a change of climate, especially to a high mountainous district may be beneficial.
The danger lies in the tuberculous sputum which should be at once burned or else put in a strong disin- fectant solution, as it contains enormous quantities of
I
TUBERCULOSIS
449
the bacilli. These, if allowed to become mixed with the dust, become scattered broadcast, carrying infec- tion everywhere.
The patients must be made to use sputum-cups; they should never be allowed to expectorate into a handkerchief, unless it is made of cheese-cloth or paper which can be burned at once, or, in fact, any- where except into the proper receptacles. The spu- tum-cups can be sterilized by steam or by being boiled in a 2 per cent, soda solution, or they may be made of paste-board and burned. We scarcely need the support of a theory of heredity in consumption: when we think of a child kissing a parent, perhaps many times daily, over whose lips thousands of tubercle bacilli are hourly passing, and when we think of that same child inhaling the dried bacilli and their spores, which always float about in the dust of a house containing ignorant or careless tuberculous patients, it would seem Strang? that the disease does not occur still more often. The popular literature on the sub- ject of tuberculosis is extensive and on the increase. Strenuous efforts are being put forth to bring the laity into line to combat the disease, and special facilities for its treatment are rapidly increasing the world over. The trained nurse is realizing mon- .unl more her re- sponsibility and the important place she holds in the ntion and cure of tuberculosis. With the dis- covery that tuberculosis is a genu disease and that it is not necessarily hereditary, it at once took rank with the preventable and curable diseases. Under favor- able circumstances the hope for complete or partial recovery is justifiable in a large percentage of cases.
»
CHAPTER XXV.
The Nl-uinc op Children.— Convalescent Children.-
Tii bit- ii, —Choi iki Inisntim iYnvilsions.— IneaN- tilt. I'akalv la. — Rickets.— Choup.— Ecxem a. —
The Infectious Diseases of Childhood.
The two periods of childhood arc infancy, which extends from birth to the age of Iwo and a half years, and childhood proper, beginning at that age and last- ing until the fourteenth or fifteenth year. The COndl turns of life during this time arc very different from :i. m i nature growth, and the principles upon which adults may be treated will not always apply to chil- dren; nor is the same kind of nursing suitable, for a nunc who may he entirely satisfactory for grown people sometimes utterly fails in caring for children.
The children's ward should always be looked upon as
ipecial department to which every nurse should go after a general experience in nursing to acquire a thorough practical knowledge of a most important specialty — the care of infants and children in health and disease If all trained nurses — and not only those who expect to do district work — were thoroughly com- petent in this branch, wc should have a large body of women whose influence and work would be of incalcu- lable benefit in decreasing die present lamentable mor- tality among infants and young children.
In dealing with children, besides tact and plenty of patience, then mwl l» a O :';iin sympathy that the lit- tle ones arc always quick to feel, and this combined
♦so
I
THE NEW HORN
45 »
with judicious firmness will make a nurse successful in the management of either well or sick children of any age. When children arc sick the habit of obser- vation on the part of the nurse ifl in the highest degree important, for, the patients being helpless and unable to properly understand or explain their own feelings, we have to depend upon signs to tell us where the trouble is located, and we may be able to gather facts of much importance from what are apparently quite trivial symptoms.
The first attention 1o give the new-born is to wash the eyes as soon as the head is born, and to see thai normal respiration is established. It is desirable, of course, that this should take place before the infant is separated from the mother. Some obstetricians li<>l<l that the cord may be cut directly the child has breathed a few times, while others maintain that in normal cases, and in the absence of any special indication, this should not be done till pulsation in it has entirely ceased. If respiration is not established after the removal of mucus from the month and contact with the air or by slapping the child on the back, a few motions accord- ing to Sylvester's method of artificial respiration may start the breathing, or mouth to mouth respiration may be tried. This may be instituted before separating the infant from the mother, but, as a rule, the cord should be cut as quickly as possible, and the child removed while some one else gives the necessary attention to the mother. Cold water may be sprinkled on the face and chest, and if this fails, immersion? in hot water, at io6° F. and sprinkling with cold water must be resorted to. • Another method of artificial respiration is that of Schultze. The operator, facing the child's
45*
XUKS/NG
back, puts an index finger into each axilla and his thumbs over the shoulders, so that their ends overlap the clavicles ami rest on the front of the chest, the rest of the fingers going obliquely over the back of the chest. The child is first suspended perpi ndicularly between the operator's knees. Its whole weight now hangs on the index fingers in the axilla ; by these menus the ribs are lifted, the chest is expanded, and inspita- tion is mechanically produced. The infant is now swung upward till the operator's hands arc just above the horizontal line, when the motion is abruptly but carefully arrested. The momentum causes the |i limbs ami pelvis of the infant to topple over toward the operator. The greater part of the weight now rests on the thumbs, which press on the front of the thorax, while the abdominal viscera press upon the diaphragm. By these two factors the thorax is com- pressed and we get, mechanically, an expiration. Af- ter five seconds the first position is again resumed, and the lungs expand and fill with air. This process may be repeated several times until the breathing seems to be going on naturally. With delicate infants it should be the last resort
After respiration has been established, the child is wrapped in a warm flannel with hot-water baps or cans near it. and left until the mother has In ; for.
Infants at birth arc covered with a white, greasy sub- stance— the vcrnix caseosa, or "cheesy varnish" ; this begins to form during the fifth month, and protects the skin from the action of the amniotic fluid; it is re- moved by applying olive oil or vaseline and afterwards rubbing the skin gently with a soft cloth. The eyes and mouth should be washed out with pure warm wa-
.
THE SEWUORX
453
tcr, separate squares of soft linen being used for the purpose If the baby hu been born prematurely or is very small, weak and undeveloped, it should be given an oil bath, after wkicli it should be wrapped in cotton wool and kept at a temperature of not less than 8o° F. for the first ten days or fortnight. In hospital cubators are used for this purpose; in private houses. as a rule, an attempt must be made to obtain the same results in other ways.
To a fully-developed child the first bath may be given at once. Before beginning, everything necessary should be ready at hand — a foot-tub. warm soft towels, warm water, castile soap, olive oil or vaseline, small squares of muslin or linen, dusting powder, a dressing for the umbilicus and clothing, the latter consisting of a diaper, a flannel band, a shirt, long woolen stock- ings, a loose long-sleeved flannel petticoat, and a sim- ple soft white outside garment — the two last long enough to more than cover the feet. The child should be wrapped in flannel, and only the part which is being bathed at the moment should be exposed.
The eyes are first bathed, separately, and afterwards the face, no soap being used, the head is then wi in warm, slightly soapy water ; very little soap should be used with infants, as it is more or less irritating, and is apt to injure the fine texture of the skin. Next one should carefully clean the parts behind the cars and the crevices of the neck, axillae and joints, and those between the buttocks and thighs. It is well at this time to notice whether ill the natural openings of the body are perfect ; finally, the baby is put down into the tub of warm water at about 96° F. and washed jff. The head and back should be firmly supported
454
XU/fS/XV
with the left hand and arm during the bath. After a minute or two the baby is lifted out, held face down- ward for a moment and rinsed off with clear warm water. It is then wrapped in a warm towel and flan- nel, and dried, not by i ■atting." Al- though one is accustomed to see the nurse hold the baby in her lap. it is a much better plan to have a table large enough to hold everything necessary for the bath, including the bath-tub and a pillow upon which to place the baby. The nurse can then undress, bathe and dress the baby without stooping and with greater comfort to the child. Powder should not be used except where there arc signs of chafing, when the best to use is stearate of zinc. Tbe navel is then dressed, a hole being cut in the centre of a of a square of sterilized lint or linen, which is slipped over the cord and folded about it ; the cord is then laid toward tlie left side, and over it is put another small sterilized cotton pad which is held in place by the flannel bandage, the nurse being particularly careful that this is not drawn too tightly. The binder may be kept on by sewing it smoothly with half a dozen large stitches, thus avoiding the danger of injury from pins. As a matter of fact, it is now held by some of the best obstetricians that a binder, far from being a -ary article, is calculated to do harm to the in- fant owing to the undue pressure exerted by it upon the ribs and the diaphragm. It certainly serves a use- ful purpose in retaining the dressings applied to the navel and in affording extra warmth. After the cord drops off, the looser knitted band should be substi- tuted. After the first bath the child is not bathed in the tub again until after the cord has dried up and is
THE NEW-BohW
455
ready to fall off, which will usually occur mi aliout tin- fifth or sixth day, although the process may be delayed until the ninth day. During the hath the temperature of the room should be about 80* I"., and the greatest care be taken not to expose the child more than is nec- essary to the air. After the bath the infant should be laid away in warm flannel wraps on its right side, on a firm mattress without any pillow. The room should be warm but not too hot, as fltn equable temperature of about 80" F. can be maintained for the first two weeks by the judicious use of hot-water bags and wraps. If care is taken in this particular, the child will prob- ably sleep the greater part of the tinw, and afterwards it may gradually be exposed to a lower degree of tem- perature. Within twenty-four hours after birth the first discharges from the bowels should come away; these consist of a dark greenish material, and arc known as the meconium. If the meconium is not evac- uated and the child has pain, a soap suppository held in the rectum for a few minutes will produce a favor- able result. An old piece of muslin should be laid in the diaper to catch this discharge, and the whole burned, as it is difficult to wash the stain out of the diaper. The urinary organs should also be watched, and if urine is not voided, flannel wrung out of hot water may be applied to the abdomen just above the symphysis pubis. Water to drink should be given from a nursing bottle. The urine of the newborn child during the first few days, may contain uric acid in abundance. Such urine is apt to be scanty, and gives a pinkish or brick-dust stain to the diaper, while the normal watery nrftM doe* not stain. Such uric acid formation probably represents a not infre-
456
NVkSMG
quent cause of colic (renal, not intestinal), during the first days of life, and suffering and illness may be prevented by the free use of warm water. Each time the diaper is removed the parts should be bathed in warm water, carefully dried, and a perfectly clean dia- per put on. The breasts of babies of both sexes some- times become swollen toward the end of the first week, and contain a fluid resembling milk. The swelling will gradually subside, and should not be interfered with, as irritation is apt to cause inflammation and ul- ceration which might permanently destroy the func- tions of these glands; all pressure upon them should be guarded against.
All the baby's habits should be made as systematic as possible; there should be regular times for sleeping', feeding ami bathing from the very first.
The best food for an infant is of course the mother's milk. Certain pathological conditions in the mother. however, make it injurious; thus the existence of tu- berculosis, fissured nipples, typhoid fever, or pneumo- nia is a contraindication to the nursing of the child, although in a case of abscess of one breast the other, if it is healthy, may sometimes be used. The infant at first should nurse every two hours during the day, and every three hours at night, say at eleven, two, and five. After the first six weeks this may be changed to every three hours during the day and twice at night. Between meals, if there be much crying, a little plain or sweetened water may be given, as the child is prob- ably only thirsty. Water should be given regularly to drink in any case. Persistent crying does not occur without n cause in these early days of life, and is usual- ly due to indigestion from over-feeding or from im-
lS'FA.xr i Eiibisc
457
proper food, to gas-accumulation, thirst, or cold. Goat's milk is the best substitute for mother's milk, but it is not easily obtained and COW'l Rltlk is ob- viously tin- next best. Kverything else being equal, the mixed milk of a herd of cows gives the best re- sults, The animals muM be healthy, well eared for Ud dean, and all into which the milk is pul
from the moment it comes from the cow until it is given to the baby must be kept scrupulously clean and uncontaminatcd. In the modification of milk the prob- lem is to change the quantities of the constituent parts of cows' milk so that the proportions shall corre-
ipond to tnoae found in human milk. The system of
percentages — the way in which exact proportions can best be expressed — was introduced mainly by Rotdl .uid Molt. The tatter's schedule, giving the aim nun M each feeding and the proper intervals for normal chil- dren is as follows :
sou : l"l ■ • Hi U.THY INFANTS
DUKiNii TIIK FIRST VF VII.
|
i |
M |
||||||
|
tn |
III |
eh Est |
Quantity 'or one (ceding. |
Quantity for 24 hour*. |
|||
|
0 ft |
i" |
||||||
|
K |
- * |
y-.s |
|||||
|
. ...,. . . |
i.r^mmo |
Ouoca |
<.i»o.n.. . |
||||
|
SdtoTlhdny .... |
10 |
-■ |
-■ |
1-iH |
310-tW |
||
|
2d and }<i wcrlt* . . |
10 |
-• |
2 |
*yx> |
15- JO |
•60-430 |
|
|
-till 4ml Mil u«,|c* . |
q |
i |
1 |
JS-IIO |
/,<> -.i |
||
|
Mil w*?k 10.1,1 nrli |
8 |
2H |
1 |
J-4H |
wj-i mi |
||
|
li month . . . |
7 |
i |
1 |
«-sX |
|||
|
Mil 10 'Jill m. mill . . |
6 |
1 |
0 |
||||
|
■-iii i.i i. iii Boats |
J |
0 |
;«-9 |
37-Ai |
1.150-1.400 |
After the third month in the case of a normal child no food should be given between the hours of 10 p. m. and 6 a. m. The food should not be given too quickly ;
458
HURS/XG
the child should be nursed for about 15 minutes, both breasts being emptied in that time. A bottle baby >lmul'l I v held while it takes its food.
If milk prepared according to the above schedule does not agree with any individual child, the propor- tions must be changed until a combination is arrived at that the child can readily digest. For sick children the changes will usually be still greater. The estab- lishment of milk laboratories in man;, of our large cities has made it possible to secure a food which in f;it, sugar and albuminoid percentages can be made accurately to correspond with breast milk. These lab- oratories have their own herds, and take the most scru- pulous care in the handling of the milk to Secure it* purity. In the laboratory the cream is separated by a centrifugal machine. In this way 16 per cent, cream is obtained which is combined with the separated milk, a standard 20 per cent, solution of milk sugar, and a standard lime-water solution. The percentages of fat, sugar and albuminoids can thus be varied, as much as is desired, the lime-water giving a slight alkaline reaction to the modified milk. In ordering the food thf physician writes for the percentages desired, die number of feedings, and the amount of each feeding, in some such a prescription as the following :
Child of three months:
B
Fat. 3 per cent. ;
Sugar, 6 per cent. :
Albuminoids, 1. 50 per cent. ;
Alkalinity, slight.
Number of feedings. 8.
Amount at each feeding, 4 ounces.
/A'/vl.W lhl;OI.\i.
459
The home modification of milk may he accomplished by using the following standard formula as a guide:
TABU FOR PREPARING WHHFUD Mil ,1 COB a iii:ai.TIIV IM .VNr
OP AVERAGE WEIGHT DURING THE SUCCESSIVE STAGES
OF ITS LIKE milM OKI Wi tO OHS VtAR.
Ac« o( Inlaot.
Milk
Cream (16 per cent, fat) .
Milk nicir (by meature, mot by weight)
Lime w»lef
ToUl amntily lor 24 hour*
(mode up by adiliii, !
water)
Quantity in each bottle (for one feeding! ....
ToUl number of bottles . Interval* between feeding
None None
J dr.
Now
s ....
4,lr. 10 2X
hn
None lot.
4 dr. 3 dr.
Sox.
6M dr. 10
2K hr>.
I oi.
I Of. 4 dr.
6 dr. 4 dr.
I.' ■■! 1 OI.
ldr. 10
2X
1 or.
4 dr.
I ,,/
I o«. Kir 6 dr.
ia«
i m
6 dr. 10
l,f
4oa, (j .h
1 dr.
I OI.
H«
1 ;>
hn.
4 oi. 6 dr. t ,., 6 dr.
lot. 7dr, I or. 4 dr.
Dm
In/.
Sdr.
3
hr».
5 o«.
4 dr.
8 oi.
2 Of.
1 ,1c J or.
Mot.
4 m 4dt.
3
1 1 ,,.•
4 dr.
1m
4 dr.
2 Of. 4 dr.
la
4dl. 42 01,
7oi.
Jet 4 dr.
3oi.
IS OK
6 oi . S oa
AM 4
l,i- In-..
Thr cream ifiould be obtained by allowing the milk to stand undisturbed in a cool place for six hours and then pouring off the top Creamy part The milk sugar is dissolved in double the amount of hot water. For measuring purposes a standard medicine glass is need- ed. The ingredients are poured into a graduated glass jug and water is added to the required mark. The mixture is then poured into bottles, a separate one being provided l\>r each feeding. These arc (li.-n stoppered with sterilized cotton and placed upon ice. Before the food is given to the child the bottle is placed in cold water which is gradually heated until the milk is warm. The temperature should be tested
460
NURSING
by shaking two or throe dropt upon the back of the
hand. The following formula suggested by Meigs may also be used:
1 part milk ;
2 parts cream;
2 parts lime-water;
3 parts sugar-water. The sugar- water is made by adding one ounce of
pure fresh sugar of milk to a pint of water. This
Formula approximate* in chemical composition to moth- er's milk. When the modified milk cannot be obtained. another simple formula is as follows: equal parls of milk and plain boiled water tied with milk
ar. with I grain of bicarbonate of soda to each feed- ing; after six months. 2 parts of milk to I of cereal
ater. The cereal water is made by taking barb neal, one tablespoon ful to a quart of water; re- duce to a pint by slowly boiling, then strain. The milk is better not Sterilized Or pasteurized, it" il is clean, fresh and properly handled. If there is any doubt dur ing the hot months from May until November these preparations should be sterilized with steam at b< point for ten minutes.
The greatest care should be taken with the bottles, nipples and Stoppers. To have them thoroughly clean and aseptic, the bottles and nipples used should be boiled each day in a 2 per cent, solution of carbonate of soda for five minutes, and afterwards in plain w.u. r. After each feedmg the bottle should be washed in cold water and then boiled, after which it is turned upsic down and allowed to drain. The nipples after Ininj, boiled are kept in a weak solution of lwric aciJ. No change in the form, of food need be made before
INFANT FEEPi
46.
ninth month, Imi 11 will have to be given, of course, in increasing quantities, and the proportions of the milk jnd water must be changed. Unless the milk is known to be quite fresh, it is safer to have it sterilized— that is, rendered free or at least comparatively free from micro-organisms. If fermentative changes have al- n uly taken place, sterilization will not render milk fit for food. A special apparatus may be had at little expense for this purpose, hut whore it cannot be oh tained an ordinary nursing-bottle may be used. A wire caster frame for holding the bottles may be bought at any drug-store. The bottles filled with milk are put in the caster and placed in a double boiler, the water being kc[ * at a temperature of 165- 1700 F. for an hour. If an Arnold sterilizer is avail- able the milk can be pasteurized if the outside jacket is taken off and the heating is continued for only half an hour, when the milk may be put away in a cool, dark place. Several bottles may be sterilized at one time, enough to last for twenty-four hours, one bot- tleful being used for a meal ; if any milk is left over after a feeding, it should be thrown away. Milk for use on a journey of two or throe days' duration may be prepared in the same way, only that the steaming pro- cess must be repeated for three successive days, just as for the sterilization of salt solution, the preparation
of which has been described elsewhere. Of late there is some evidence to show that children fed for a long time on this milk (sterilized at too" C.) do not do well. It is probable that the high temperature produces cer- tain chemical changes in the milk which Is -en its nu- tritive properties. Subjecting the milk to a tfl lure of 60 to 70* C. for half to three-quarters of an
462
VUJtSWG
hour — fasleunaitiOH — will destroy the bacteria likely to be present, thus delaying fermentation, and secures the advantages without the drawbacks of heating the food at the higher temperatures.
After birth several physiological changes take place in the child. The bones, which at first arc very soft and flexible, require some months to ossify and be- come firm enough to support the child, so that it can stand alone. A child should not be allowed to try to 'I before it is a year old, and if permitted to sit alone it should not be left in this position for any length of time, unless some support is given to the back, because curvatures are apt to result if the weight of the body is thrown too early upon the slender bones. A child should be very carefully handled, as tossing it and throwing it up and down may cause serious in- jury.
The head may be of a peculiar shape, which may have been caused by pressure during birth. The bones of the skull do not unite firmly for some months, and the fontanclles must not be pressed upon, but the greatest care should be taken to protect them from injury. The sutures arc yielding, and sometimes at birth the edges of the bones overlap. Very marked peculiarities in the shape of the head or of its bones may disappear after ;i few weeks' growth.
The stomach at first is very small, and very little food, one or two tcaspoonfuls, will be sufficient f<> feeding; when too much is taken the surplus will be regurgitated, a condition often mistaken for vomit- ing.
The stomach capacity, however, rapidly increases. At the end of the first week an average child requires
INFANT FEEDING
4<>3
from one to one and a half ounces at each feeding ; in its second and third week, from one and a half to three ounces; in the fourth and fifth weeks, from two and one-fifth to throe and a half ounces; from the sixth week to the third month, from three and a half to four and a half ounces : at six months, six ounces ; and at twelve months, from eight to nine ounces arc re- quired.
The skin soon undergoes changes: during the first few days it is red, later it becomes yellowish, and nfter a few more day* assumes its natural color. In catarrhal jaundice the conjunctiva arc also tinged. The sweat glands do not become active until after the first two months.
The average weight of a newborn child is seven pounds; for the first two days it loses weight, and after this gains from two to six ounce* a week.
A baby should be weighed daily during the first weeks of life, and at less frequent intervals during the year, for its weight is the best index of its nutri- tion. The weight, the stools and the urine arc all useful indications of the child's condition.
The following table shows the average gain of a hcalthv infant:
sat.
PirM mi-.nth S. .... f i ■ I Third Fourth Fifth
Sixth
Seventh "
Klcluh "
Ninth " Tenth
Eleventh "
Twelfth "
Monthly Gain.
IJV ouncei
8M -
ji
11 '. I •
3» •
11
7
Weight »t end of the
Bonn,
* pauniU i% ounce*
4 IS 9!<
»«X
JH S
10
0 7
4^4
NVRS/XG
For the first six weeks a child -.honld sleep twenty houn nut of the twenty-four. From the very first it should be put quietly down, and allowed to go to without rocking or mining.
Regular bathing is of the greatest importance to a child's health. One bath should be given daily, not too close to the timi- for a meal, in a room of which the temperature is about 75' F. The temperature of the water should at first be 95" F., but after the child ha* reached the age of three months it may be low to 90* F. During the first three or four months the child should not be kept in the bath longer than two or three minutes.
At the age of six months it is well in the case of a healthy baby to finish the bath by a splash of cold water at from 650 to 75*. or with a cool sponging followed by a brisk rub.
The disorders common in the newborn are colic, jaundice, opthalmia neonatorum, thrush, and aliYc tions of the umbilicus. An inflammation of the un> is probably always due to infection, and tin- physician's attention should be called to it at once. Ii" any moisture appear.-* about the cord, iodoform or,
better still, a powder made of 1 part of iodoform t'» 6 parts of powdered boric acid, may be sprinkled al It, and a pad of sterilized gauze applied The infl mation. unless checked, may prove serious, as the gen- eral strength Eaila rapidly, abscesses may form, and the cbilil may die. If granulations appear after the cord has dropped off, nitrate of silver in solution or stick is usually ordered m In tly, the wound
being afterwards dressed with the iodoform and boriCr acid powder.
OPHTHALMIA iSEONATOKtM
Colic is a very frequent disturbance, and one that begins very early in a child's life; it is due to an accumulation of gas in the Stomach or intestines, and is usually caused by over-feeding, rapid feeding, im- proper food, or exposure to cold. The pain, which comes on in paroxysms, is sharp and griping. The chQd Hidden!) nttcrs a sharp cry, the legs are drawn up, and on examination the extremities are found to be cold. With care in feeding and keeping the body sufficiently warm many of these attacks can he m id cd, and frequently, when one comes on. the pain v. ill Cease if the child he held before the fire until it is well warmed through. Hot flannels to the abd have also been recommended, and internally a little warm water or peppermint-water may be given for two or three doses to relieve or expel the gas. The body may also be well rubbed with warm oil. Sim- ply raising the child up often gives relief by facili- tating the escape of gas. Stimulants, paregoric, sooth- ing syrups (most of which contain opium) should not be given under any consideration, limplc heal be- ing in the majority of cat as effectual In persistent cases the colon may 1" washed out with i | lint of warm Ntcrile water once a day.
Icterus, or jaundice, is often seen during the first and Second weeks of life, hut is not considered of much importance if the general health is good, as it mi! without treatment after a few days. The bowels should be kept freely open.
Ophthalmia neonatorum is an inflammation of the superficial tissues of the eye, particularly of the con- junctivae. Both eyes are usually affected. In the newly-born the cause is to be sought for in an in- *»
466
KUKS/NG
fection during birth from the urethral or vaginal discharges of the mother, or the pus-producing or- ganisms may be introduced afterwards by care- lessness in handling. As a preventive the moment the child is born and before its eyes are opened, the nurse should wipe carefully away all discharges, using fc UlC purpose separate small squares of cotton or gauze ft$ wrung out of a weak solution of boric arid. The eyes should not be exposed to cold air. At the first batli the eyes should be bathed first, and the same piece of linen should never be used for both. In some lying-in hospitals, especially in suspicious cases, as a matter of routine one drop of a 2 per cent, so- lution of nitrate of silver is dropped into each eye. At the onset of ophthalmia a slight redness of the eyelid about its edges is noticed, with a little swelling; this condition rapidlv becomes worse, and at the end of twenty-four hours the swelling has increased, so that the eye may be wholly closed ; the eyelids and conjunctiva? are deeply injected, and pus oozes out. In some cases the purulent discharge is very abun- dant. ;iud there will be danger <>f the destruction of the cornea by ulceration and perforation with result- ing blindness for life. Upon the slightest indica- tion of redness the eye should be frequently bathed with a warm weak solution of boric acid, and sometimes cold compresses will be ordered. The use of lotions and poultices should be avoided. In any case the physidan ihould be notified at once. In bathing the eyes no friction should be used, and the lids should be gently held apart, no pressure being exerted on the eyeball. When pus appears, the eye ghoaM be washed out every hour, every half hour,
THRUSH
467
or even oftencr. This may be best done by letting the solution run over it from a medicinc-droppcr. After being allowed to trickle from the outer to the inner angle of the eye, it will then run down beside the nose, and can be caught on a piece of absorbent cotton or sponge. Where there is much pus, the eye may have -to be irrigated in this manner every fifteen minutes, day and night, as the only way to save the cornea is to keep down the inflammatory process. When this has to be done at such frequent intervals, a ■mall fountain syringe with a glass nozzle attached will afford a steady flow of the solution. No forcible stream should be used. Precautions should be taken to prevent the other eye from becoming infected, and no particle of the discharge should be allowed to touch it ; in very bad cases the sound eye is sometimes cov- ered. All sponges and cloths used should be at once burned, and the basin which has held them filled with 1 :20 carbolic-acid solution. The nurse's hands should be thoroughly scrubbed in hot water and soap, and disinfected with the same solution, as the disease is highly contagious and dangerous to adults. Touching the face or hair should be avoided unless the hands arc quite clean.
Thrush, or sprue, is a disease in which small whitish spots or ulcers spreading into patches appear on the tongue, the sides of the mouth, and the gums of in- fants ; in severe cases the process may extend over the entire cavity of the mouth, into the throat, and even down the gullet into the Stomach : •■"iiu-iinics, although only very raj"*!/, il iias been known to invade tin in tcstincs. In serious cases the child may die of inani- tion, the throat and mouth being too tender and pain-
46S
NVRStNG
tul to permit of swallowing, or at other times death Mi.i-. result from the exhausting diarrhoea, which may I" present Tltesc patches result from the growth of a yeast-like fungus. Milk should not he allowed to remain along the sides of the mouth, hut each time after food has hecn given the mouth should lie washed out. The disease is combated with an alkaline wash, usually a borax solution (twenty grains to an ounce of water), It should he applied every two hours with .i -.-:i i : i-.-l" - -hair brush until signs of improvement ap- pear, fa all cases the child is fretful and irritable, and in (he severer forms there will probably be diarrheca. The discharges from the bowels are very acrid and cause excoriation of the buttocks and surrounding membranes, unh --. precautions are taken. Melted nmi t < hi suet applied 1" tlu-M pans 1 miiis ;i matin- and pro- tection against the irritating effects. Thrush some- times appear* in adults in the later stages of tuber- culosis and of some fevers.
The character of the stools in infants should always be noted, as from their general appearance we can often tell whether the food they are receiving is suit- able or, if not, what constituent is not agreeing with them.
Stools that arc green when passed arc pathological, but even normal Stools may show greenish areas after the) have remained on the diaper for some time. Curds in the stools consist of undigested material. Undigested fat usually takes the form of smooth flat or round masses about the size of a pea or bean. Hard whitish-yellow or greemsi. lumps are generally made up of casein. Too frequent yellow stools arc often caused by the ingestion of too much cream.
DIAKKHOEA
469
Foul smelling stools are often due to an excess of albuminoids; In severe diarrheas the stools are liq- uid but sometimes practically odorless.
Too often an attack of diarrhoea is neglected be- cause it is ascribed to teething; In normal children, who arc properly ted and cared for. the eruption of the teeth should take place without cau.Miig any marked constitutional or systemic disturbances.
Ilutentis in children is known according to its form and severity by different names — viz. acute dyspeptic diarrhoea, cholera infantum, and acute entcro-coh
Diarrhvai is a disorder that occurs :u 1- children
chiefly during the hot summer months, and is attended with a high death-rate. The majority of cases arc noted during the first two years of life. It is due, as are SO many children's disorders, to disturbances in the digestive tract. It is more common where improp er forms of food have been given, and where suffi- cient attention has not been paid to cleanliness. Bot- tle-fed infants are very liable to it. particularly among the poorer classes, owing no doubt to impure milk and ignorance on the part of tin mothers, who neglect to keep the feeding-bottle clean. As a rule, a child should not be deprived of the breast-milk during the hot months of summer, as diarrhoea almost invariably follows, but there are cases in which the mother's physical condition is such that the physician is com pellcd to order an immediate weaning ot the child.
With older children the diarrheca is associated not only with the use of tainted milk, but frequently fol- lows the eating of improper foods, such as unripe or decayed vegetables. In all cases it is believed that the diarrhoea results from abnormal fermentative pro-
470
XV/f.WC
cesses due to bacteria. Summer diarrhoea may be first signalled by an increased number of evacuations from the bowels, with griping pains in the abdomen, which make the child fretful and restless, or it may come on suddenly and manifest itself by vomiting, griping pains, frequent evacuations, and fever. Care in the diet, giving only rice-water or albumen-water, and keeping the child quiet in bed, if possible in the open air, may be sufficient. Castor oil or calomel, one-sixth of a grain every hour for six doses, is usually ordered at first to remove the irritating cause. In the more se- vere forms, where there is much irritation of the stom- ach or intestines, die stomach and colon arc sometimes washed out. To wash out the stomach, a large soft- rubber catheter and glass funnel arc used instead of the regular stomach-tube, and for irrigating the colon a catheter of the same size is used, being introduced as far as six or eight inches, and a pint or quart of lukewarm normal salt solution is allowed to pass in at one time; if there be fever, cold water may be substituted. An ounce or two of normal salt solution or sterile water is put in, and siphoned off. This is repeated until the flow is clear when an ounce is put in and left that the stomach may not remain empty. The baby should be allowed to sleep after this treatment Milk, if given in severe cases, should be modified and sterilized. In severe cases nothing but warm watet should be given for some hours. Egg-albumen, bar- ley-water, or rice-water, may be given instead. Beef- juice or mutton-broth are, as a rule, inadvisable in the hot summer months. A formula often used is j milk 2 cups; cream 2 cups; lime-water % cup; boiled
BNTEHO-COU I is
47 •
water 2j4 cups. Divide, put into feeding-bottles and sterilize.
In addition to a strict regulation of the diet, a change of air will generally prove of the greatest bene- fit. The poor emaciated weakling from the city it often restored in a very short time to health and vigor if it can be removed to the country.
Cholera Infantum, a disease less frequent than sum- mer diarrhoea, but one which is extremely serious, is generally preceded by some mild disturbance of di- gestion, but may come on quite suddenly. It begins with continuous vomiting and frequent thin, watery stools, which arc at first very offensive. The child has fever, the eyes rapidly become sunken and hollow, the features look pinched, and in extreme cases symptoms of collapse soon come on. The pulse is rapid and feeble ; there is excessive thirst and restlessness at first, which may be followed by a condition of stu- por. Starch and laudanum injections may be ordered; if so, they should be given cold and introduced high up. the itarefa having been previously well boiled. The child should be kept absolutely quiet. Plenty of water or cool barley-water may be given, and the food for a time will usually consist of egg-albumen with a few drops of brandy.
Entero-colitis, or Catarrhal Dysentery, is an acute inflammation of the colon and ileum, ;m<l may also fol- low an ordinal . attack of diarrhoea. There are con- stant pain and fever, the Itooll are mixed with blood and mucus, and. in fact, sometimes consist almost en- tirely of these two element*, \u attack may end fa- tall} after forty-eight hours. Irrigation of the intes- tines may be ordered, and the nourishment is much
47*
NURSING
iiu m in the other diarrhoeas. In any of these diseases there arc apt to be charing and soreness of the skin about tin- hip*, which is kept almost continually wet by the fretpient discharges. The bathing may be done with very thin boiled starch-water in place of soap and water, or v, ith toft cloths dipped in lukewarm olive oil. and the parts afterwards nibbed with vaseline and dusted with steaiate of zinc or oxide of zinc finely powdered. A flannel bandage should be worn over the abdomen and stomach, and kept on until the child has fully recovered. For the prevention, as well as the cure, of all such diseases, the child should al- ways be kept properly clothed, the abdomen being more especially protected. Other hygienic precautions and care are of the greatest importance. A nurse, particu- larly a district nurse, may do much towards the pre- vention of such cue*. If she fully realize the impor- tance of hygienic measures, and the results which al- most certainly follow, and can induce the mothers to care for their infants properly, her privileges and op- portunities for saving the lives of young children will be almost unlimited.
Constipation frequently occurs in infancy and early childhood. The bowels should be opened once in twenty-four hours. For an infant, fluid magnesia may be given in the milk. A small suppository made of soap held in the rectum sometimes may he sufficient, or. ac- cording to the age of the patient, from a teaspoon fill to a tablespoonful of sweet oil may be injected by
meant of a small robber lyringe and allowed to re- main from half an hour to an hour and then followed by a small, timple snap-suds enema. An injection of glycerin given with a medicine dropper to an infant
CONVULSIONS
473
or half a teaspoon ful to a larger child is also very ssful in emptying the lower bowel. The glycerin suppository may be used instead. It is not safe, 1< v ever, to depend daily upon these aids to emptying the bowels. It is better to look to the dii I. giving plenty of water, and at the nine time establishing the child in lar habits by putting it on the chamber at the 9ime time each day. Nothing should be allowed to interfere with regularity in such habits. Gentle rub- bing or massage of the abdomen with circular move mentS from right to left with ;i little sweet oil for ten minutes daily Will help to increase the action of the bowels and bring on a normal movement With older children plenty of exercise and i daily cold sponging of the body followed by brisk nibbing are recommend- ed. Little, it anything, in the way of drugs should be employed for constipation.
Cot: may occur as a complication in
diarrhoea, and frequently result from improper feeding. - -• nit;. -:;..n ..f tin brain) affection! of die ear, rickets, urscmic poisoning and the infectious fevers. such as measles, scarlet fever, or whooping-cough. They m occasionally due to reflex irritation from teething; the pricking of a pin, or the presence of worms may produce nervous excitability, and where other condi* linns tend this way convulsions maj follow. The at- tacks occur more often during the first year of life, and may come on quite suddenly : or the onset may be gradual, restlessness with twitching and grindio the teeth being a premonitory symptom. The hands stiffen first, and afterwards the whole body becomes. rigid ; the eyes are staring or rolled upward, fa a
few moment) the muscles relax, and twitching or con-
474
MKSf.VG
vulsivc movements arc seen in the limbs and arms; gradually these cease and sleep follows. In bad cases the seizures may follow each other in rapid succession. If (lie physician is present, he usually gives chloro- form during the attack ; if the cause be over-disui of [lie stomach or indigestion, an emetic is given, and is followed by an enema. A warm bath is custom- ary ; this should he givt-n with care, so as not to cause too severe a shock. The temperature of the bath Should be 960 to 100° F. — not hotter; the warmth will relax the muscles and induce perspiration anc sleep. The head should he kepi cool In cold com presses or by means of an ice-cap. Any possible source of irritation .should he searched for, and when found should be removed.
Meningitis is an inflammation of the meninges of the brain or spinal cord ; it may come on gradually and insidiously, or develop suddenly with continuous convulsions. It usually comes on in the former man- ner, with symptoms of frctfulness, restlessness, intoler- ance of light or noise, headache and vomiting and, as the disease advances contraction of the pupils and con- vulsive attacks may occur. The bowels should be k< freely opened, perfect quiet enforced, the room dark- ened, and all causes of excitement kept away. Only liquid food at regular intervals should be given, anc plenty of fresh air with thorough cleanliness is in- dispensable. Warm tub-baths are sometimes ordered.
Infantile paralysis (acute anterior poliomyelitis) usually occurs in children under three years of age. It begins usually with high fever and convulsions, which are followed in a day or two by a more or less marked loss of power and atrophy of the muscles. A
CHOREA
475
physician should be called at once. The treatment at first will probably be limited to keeping the child in bed to reduction of the fever and the proper regula- tion of thi- Ikiwi Is. After the acute stage is over mas- sage and passive movements of the affected limb, plenty of light nourishing food and fresh air, are recommended. A nurse is often ordered to apply electricity for the purpose of giving a certain amount of exercise to the muscles, and thus keeping up their nutrition.
Incontinence of urine is of frequent occurrence, especially in nervous children. It may be met with in connection with di which -are accompanied by
other and more prominent symptoms, or may be due to an increased quantity or to too great an acidity of the urine, to weakness of the sphincter muscle, or to the presence of pin-worms in the rectum. The child should be placed under the care of a physician, and regular habits of urination should be formed ; if he is old enough, he should be taught to exercise his will- power. H<' should not be allowed to drink much in the evening. He should always empty the bladder just before going to bed for the night, and should sleep with the foot of the bedstead elevated.
Chorea is a disease in which there are irregular movements produced by involuntary contractions of single muscles or groups of muscles. It is commonly spoken of as St. Vitus' dance. Young girls and boys of a highly nervous temperament develop it most fre- quently. Absolute freedom from excitement and worry should be provided for, besides the best of hygienic surroundings, the child being amused in a quiet way, and in all severe cases kept in bed. Nurses
476
\ t AS/.VG
should always know how to manage such cases, as 0 have the care of the patient with only oc- casional visits from the physician, and a great deal depends upon proper nursing. In severe cases of chorea, where the child is losing much sleep and be- coming exhausted, the application of the hot usually relieves the nervous strain and produces
Rickets, or rachitis, is a disease of childhood, char- acterized by deformities in the bones, owing to in- creased cell-growth in tl»em, with a deficiency of lime- salts. Xon-hvgicnic surroundings and improper food are the main causes, and the substitution of cleanliness, wholesome- food, fresh air. and ine will effect
more than drugs. The child is generally pale and delicate-looking. The head may be unusually large, and the changes in the shape of the long bones ir often noticeable; the legs are apt to be more or less bowed, or the child may be knock-kneed. A most im- portant point to remember is that deformities may often be prevented in the early stages if constant care is taken by the mine i" carrying and holding the child properly. The condition is most common among the children of the poor in crowded localities.
Croup among children occurs in two forms — the false or spasmodic, and the true membranous or diphtheritic croup. The spasmodic form is supposed to arise from spasmodic closure of the glottis ; it comes on suddenly, and may be the result of exposure to damp and cold, of cxcii 01 of indigestion. This
false croup is not dangerous, but the symptoms are alarming, especially when, as most fn hap-
pens, the attack comes on during the night : the child wakens from a quiet sleep with a hoarse cough, dif-
ntrimiERiA
Ml
ficulty of breathing, ami the mother fears that suf- f< nation is imminent, since the face sometimes be- comes perfectly blue. The spasm ceases abruptly and the child goes to sleep, but the breathing continues to Ik- croupy daring the night. Sponges of flannel wrung out of hot water arc first applied to the throat, hot bath or a mustard foot-bath is sometimes gi These simple measures will relax the spasm, although they may not relieve the croupous breathing, which, however, is not serious. Should warm applications fail, a moist air-tent may be Improvised, (-ee p. 200). An emetic consisting of a drachm of the wine or syrup of ipecac, repeated every half hour till free vomiting occurs, and a simple enema, are generally v.Tv effective. The attack frequently comes on for three nights in succession, an hour or so earlier on each succeeding night. One should try to prevent an attack by taking precautionary measures during the thus the bowels should be freely opened with a dose of castor oil. only Ught forms of i ild be
given, and the child kept in a uniform temperature.
In membranous laryngitis a false membrane is formed in the larynx, and in iv thicken gradually until the passage is quite closed between the cords ; in such cases, if the patient does not succeed in coughing up the obstructing material he is liable to die from asphyxia, and even where the membrane is not so extensive death may result from exhaustion. It is always well to consider this membrane as due to diph- theria, and to isolate the patient. The symptoms come on gradually with a wheezing sound from spasm of the glottis, and as the membrane accumulates there is evidence Of depression throughout the •.■.:■•
47*
jWa:s/x<;
tern. The temperature m n range from 1030 to 1040 I", (although in some cases the patienl may have very little or no fever) . the pulse-rate may be increased, and the disease may terminate fatally after twenty-four or eight hours. The air breathed should be moist, a steam kettle filled with lime-water may be kept boil- ing in the room, with the steam directed toward the mouth from a moderate distance. Careful attention to the diet is necessary: beef-juice and milk and stimulant*, if the pulse indicate them, will be ordered. and it is usual to allow plenty of water to drink if the patient be thirsty. While waiting for the physician the nurse may make preparations for intubation or tracheotomy, cither of which operations may be ex- pected at this stage.
Eczema in children takes on various forms; the af- fection is an inflammatory disease of the skin. It may occur within a very short time after birth, arid is some- times the result of improper care on the part of the muse. The flannel in which it is wrapped may be too irritating and rough for the tender, delicate skin of the child, nr . ■•■ all amount of friction may
produce chafing or redness. Again, the ointment or oils used m.-i\ have been impure, or the child may have been kept too warm. Eczema may also be due to reflex irritation from the alimentary canal. Further. the feei •- and urine are irritating, and unless the infant be properly bathed and dried an eczema will be sure to appear over the areas subjected to irritation. The eruption occurs chiefly in the folds of the neck, be- hind the cars, on the head, under the arms, about the buttocks, and in the groins. For such patients soap and water should not be used for bathing purposes,
fc
MEASLES
479
as they are irritating, but some bland mucilaginous wash, such as thin starch-water, bran-water, a solu- tion of bicarbonate of soda, or flax-seed tea, should be substituted, as these soothe the itching which is always present. On the scalp irritation may soon appear, un- less care is taken to remove all of the eernix caseosa. As a rule, however, gentle, careful cleaning, preceded by a good oiling, will soften and remove it Beside thorough cleanliness, whatever treatment is prescribed by the physician should be faithfully carried out.
A rash appearing on different parts of the child's hcxly m.i\. hi'wcver, i>e due not '" eczema, bul i" one of the eruptive infectious diseases that occur in child- hood more frequently than in adults, such as measles, scarlet fever, rubella, and chicken-pox.
Measles may occur at any age, but is most frequent in childhood ; it is an acute, highly contagious disease, which may be divided into three stages — viz.. tlmse of invasion, eruption, and desquamation, respectively. The average period of incubation (•', c, the time which elapses between exposure to contagion and the onset Of the first symptoms) is from ten to fourteen day* 01 even longer. The stage of invasion lets in with coryza. simulating somewhat an attack of influenza, the running at the eyes and nose being accomp. by a hacking cough, fever, headache, and loss of ap- petite. The fever is highest on the third or fourth day, reaching 1050 F. or more, and the reddish eruption appears usually on the morning of the fourth day, first upon the forehead, tlun upon the neck and chest. until finally the face and entire bodj are covered with it. At first small red IpOfa appear, which increase ill size, and finally run together, and the papules or
4«o
NURSING
little elevations may be felt distinctly on passing the fingers over the skin. After two days the eruption begins to fade, the fever abates, and the catarrhal syinpi'ims disappear, but the cough may continue for some days. As the eruption and fever decline desquamation or peeling off of the skin in fine branny Kales begin -. Hi.' i-liilr! should be ki pt in bed "ii milk, or on light diet if there be little fever, the bowels should be made to move regularly, the temperature of the room should be kept at 68° F.. ami the vtntila tion looked after: exposure to sudden changes in temperature should be guarded against. If the rash d«K"s not i-nme out well, hot drinks or a lint bath and wrapping the child in flannel may hasten its appear- ance. The room should be moderately dark for the first few days, or the eyes should be protected from the light, as there is generally marked photophobia. When desquamation begins, the whole body may be smeared with vaseline or an oil bath may be given daily, usually in the evening, and a warm-water batfl in the morning; usually some antiseptic is mixed with the oil or ointment The complications in measles arc often more serious than the disease itself ; of pneumonia or broncho-pneumonia is the most common and perhaps the most dangerous; bronchitis is also very frequent) and some degree of conjunctivitis is nearly always present. Isolation is usually kept up for a week after the peeling has ceased, and tin- cloth- ing and the room must afterwards be disinfected as in other infectious diseases.
Rubella (German measles) is a contagious disease which spreads rapidly. The period of incubation is about ten days or a little longer, The initial symptoms
WHOOPING-COUGH
481
are coryza, chilliness, pains in the back and legs, ami some fever. The eruption appear* first on the face and chest, and very soon spreads over the body. In ap- pearance it resembles that of measles; after two or three days it fades away. The disease is usually mild, and the giving of a light diet, keeping the bowels active, and confinement to the house in a room of a warm equable temperature for about a week will be all that is necessary.
Parotitis, or mumps, is an inflammation of both, more rarely of one of the parotid glands, involving also the surrounding connective tissue ; it is an infectious and a contagious disease. Tbc period of incubation varies from eight to fourteen days nr more. The onset is usually marked with a chill, malaise, headache, and some rise of temperature: in nervous children con- vulsions often occur. The disease reaches its height in from four to five days, after which the pain and swelling gradually subside. Warm fomentations may be applied to relieve the pain, the bowels should be kept open, and soft non-stimulating food given. The ventilation should be good and the room kept at an even temperature. It is best to keep the child quiet. Isolation should last three or four weeks. This specific parotitis differs from that seen sometimes as a complication of typhoid fever ; in the latter suppura- tion is the rule.
Whooping-cough or pertussis is an infectious disease beginning with a catarrh of the air-passages, just Hkc an ordinary cold. The incubation period varies from seven to ten days. There is some fever, wheezing, and a short dry cough : at the end of eight or ten days the cough becomes worse and is associated with the
482
NUKS/XG
characteristic "whooping sound" ; this whoop is really a prolonged inspiration occurring at the end of a paroxysm of coughing; the expirations arc short ,-iml spasmodic. At the end of a fit of coughing a frothy mucus is expectorated. Vomiting is very common and often seriously interferes with the nutrition of the patient. This stage lasts from six weeks to three months, or even longer. The child should be kept away from other children, and in bed during the first stage and while the fever lasts. Plenty of fresh air should be provided day and night. Inhalations of steam are sometimes prescribed for the cough, while easily-digested, nourishing food is given throughout the whole course of the illness. In the later stages a change of air is advisable, as it often shortens the duration of the attack.
A high temperature and a rapid pulse arc not con- sidered such serious symptom*, in children as in adults. The temperature in children should always be taken by the rectum, and the pulse during sleep will always be more reliable.
In all of these diseases peculiar to children the nursing forms a most important part, and upon the skill, intelligence and sympathy of the nurse the com- fort and well-being of the little patient largely depend.
CHAPTER XXVI.
Obstetrics.— Pregnancy. — Symptoms ani> Physical Signs.— Development op the Foetus.— Abortion.— M iscakhi.m.e,— Premature Laiior.— Care of the Patient bfiore, im lis... and after labor.— care of the breasts.— care of the Child.— The Puerperal State.
The impregnation of the ovum, wlii.li fa tO result finally in the formation of a new being, constitutes what is called conception. The ovum lodges in the uterus and, remaining there, gradually develops until the fectus matures, when it is expelled, under normal conditions, in the shape of a well-formed infant tn the beginning the new organism is called the embryo, after the fourth month the fcetus. The symptoms and signs of pregnancy are numerous. Among the first to appear after cessation of the menses are nausea and vomiting (morning sickness), which, however, are generally met with only in the early months of preg- nancy. In some cases (here may Ik- ..mtv slight nausea on rising, which does OOl result in actual vomiting. and ;is a rule the nausea and vomiting of pregnancy amount to nothing more than an inconvenience, but occasionally this symptom is aggravated and may be- come of grave Import A few weeks after conception there can be noticed some enlargement of the breasts and a darkening of the areoLx ; the breasts become fuller, and the woman often has a throbbing sensation in them; the superficial veins become distended.
483
4«4
IfVRSfXG
The change* in the size of the abdomen are depend- ent upon the progressive enlargement of the uterus, which also gives valuable indications as to the stage of pregnancy that has been' reached in any particular case. The uterus at first is low in the pelvis : at some time during the fourth month the fundus is on a level with the brim of the pelvis; by the end of the fifth month it has risen halfway to the umbilicus ; and at the end of the sixth is on a level with it. At the end of the seventh month the fundus is midway between the umbilicus and the tip of the sternum: at the end of the eighth month it reaches to the xiphoid cartilage ; finally, during the ninth month the uterus again sinks a little in the abdomen. Between the eighteenth and the twentieth week quickening is first felt ; that is, the mother first becomes conscious of the movements of the child. From the fifth month on, the foetal heart may be distinctly heard on listening with the stetho- scope; the sound resembles the ticking of a watch under a pillow. The rate of pulsation of the fcetal heart varies from 130 to 160 beats per minute. At- tempts have been made to determine the sex of the ihild before birth by the frequency of the heart-beats. the pulse being generally a little slower in larger children, who are more commonly males, but no trust- worthy diagnosis can be made by this method. Changes also take place throughout the whole body of the pregnant woman ; the heart, having more work to do, enlarges a little, and there is a general increase in tension in the arterial system. Sometimes there is swelling of the thyroid gland.
The obstetrician is often able to diagnose pregnancy very early by a vaginal examination. The vagina as
r/tiiGNAXcv
485
early as the third week assumes a bluish tint, owing to the dilatation of the veins, and, what is more important, the cervix of the uterus becomes softened. In women who have never been pregnant the cervix feels as hard and firm as the tip of one's nose, but at the end of the first month of pregnancy it is much softer. There arc often marked digestive changes: the appetiti- may be capricious, and there may be a craving for particular kin. Is of food; the salivary secretion is increased. Wherever pigment is found normally, it is increased in amount in pregnancy, thus, there is often a deep- brown line running from the umhilicus to the pubes, and the face nearly always shows alterations in tint. Occasionally the latter is very much pigmented, and we have the so-called masque des femmes enceintes. The nervous system may be influenced in a striking manner: sometimes nervous, irritable women become quiet and amiable, while those who have been even- tempered and genial become cross and excitable. The quantity of urine is increased ; there may be functional disturbances, such as frequent, painful, or involuntary inic lurition. Albumin is sometimes present — a sign which always makes a physician anxious: the bowels m:i. lw constipated. Headache, neuralgia, hemor- rhoids, varicose veins, and insomnia arc not uncom- mon. Chorea is a dangerous complication. The pKtk-nt should be under the observation of an obst> in cian from the beginning. A specimen of urine should be sent to him for examination every ten days or at least once a fortnight.
The average duration of pregnancy is 280 days, or about nine calendar months. The probable date of confinement may be calculated in two or three ways,
486
NUMStNG
hut the one considered the most accurate is to cou..t back three calendar months from the date of the ap- i>< .ii.in. <• nf ill. last menses and add seven days. Toil will give us tin mouth and approximately the day. In first pregnancies — or, as we say. in the case of primi- parw — labor is apt t<> begirt a week earlier than this, as the uterus is not so tolerant of distention as it may af- terward be in later pregnancies.
Ballotlemcnl (from the French ballottrr, to toss up like a ball) is another means of diagnosing pregnan The examining finger is placed in the vagina, while the other hand presses slightly on the abdomen ; the fecttis is poised on the finger in the vagina, and then tossed up till it strikes the outside hand, after which it will return to its lnrniiT position with a gentle tap. This can generally be appreciated at any time after the fourth month : the sign, which is known as internal ballottement, may be absent if the amount of amniotic fluid be small ; external ballottement is a sign of less value.
The fectus receives its nourishment from the mother through the placenta! vessels. The arrangement for the interchange of substances in the placenta between motbei ami child is most wonderful. The uterine and placental vessels fit into one another like fingers into a glove, and so thin is the membrane between the two that nutrient substances coming from the mother and waste substances from the child returning to the mother pa .li easily.
The development of the foetus begins, as we have said, with the impregnation of the ovum, which entering the uterus, becomes attached to its mucous membrane, usually on the upper part of the anterior or posterior
THE PLACENTA
487
uterine wall, but rarely at the fundus. At the point of junction of ovum and uterine mucosa the placenta is formed. The fcetus becomes enclosed in several membranes, the formation of which is too complicated to be discussed here, but which will be found fully described in any treatise on embryology.
The membrane nearest to the fcetus, and which con- tains the fluid in which the latter is suspended, is known as the amnion, the fluid being called the am- niotic fluid ; while the external coat is designated as the chorion. The umbilical cord contains the blood- vessels which run between the foetus and placenta. A fully formed placenta occupies about one-third of the surface of the mucous membrane of the uterus. It is round in form, from six to seven inches in diameter, and about one inch thick ; the surface next the fcetus is covered by a smooth membrane, the amnion, while the uterine or maternal surface is rougher, and is divided by shallow furrows into fifteen or twenty smaller areas, which are known as cotyledons. The placenta is connected with the fcetus by the vessels of the umbilical cord, and the facta! vessels communicate with the uterine vessels of the mother — not indie. I directly, for, as we said, the two bloods never mix. The placenta is the organ by means of which the respiratory, excretory, and nutritive functions of the foetus arc carried on ; the umbilical cord is attached to the placenta at one end and to the umbilicus or navel of the child at the other. It is from sixteen to twenty inches long and about half an inch in diameter. It is covered by the amnion, and is mainly made up of a peculiar tissue called WhottOlti jelly; it contains the umbilical vein and the two umbilical arteries ; tlw
488
XUHS/NG
carries the blood from the placenta to the foetus, and the arteries return it.\
The tenns used for an uncompleted pregnancy are abortion, miscarriage, and premature labor. When the ovum is expelled at any time during the first three months of pregnancy, we say that an abortion b taken place: when the expulsion occurs at any time between the third and seventh months (i. e before the child is viable), we call it a miscarriage; a premature labor is one which occurs between the seventh and the end of the ninth month.
The care to be given in nursing a case of abortion is, if possible, even greater than that required in one of normal labor: the latter is a natural, the former a pathological process. There will be more danger of haemorrhage and more shock to the nervous system. The patient must be kept absolutely quiet, and much attention must be paid to diet and cleanliness. The symptoms of abortion are pain and haemorrhage ; the latter may be excessive, owing to a partial separation of the placenta from the walls of the uterus. Be it is always more difficult for the uterus to regain its normal condition after abortion than after labor at term.
Treatment of Abortion. — In a case of threatened abortion the doctor should be sent for at once, but If the symptoms arc slight, absolute rest in bed and the avoidance of all mental excitement may be the only treatment necessary. If, however, the abortion seems inevitable and there is much haemorrhage, the patient !>e kept perfectly quiet, with the foot of the bed- stead elevated, and in an emergency the nurse may be obliged to tampon tho vagina. If abortion takes place
CONVULSIONS
489
before the arrival of the ' : ill discharges DMMt be saved in a covin 'I Il.mii foi bis inspection.
The rupture of the membranes some time prior to labor may be considered as an accident. The patient should be put to bed, kept perfectly quiet, and the doctor notified.
Antepartum hemorrhages. — Any bleeding from the genital canal occurring during pregnancy is a sure sign that all is not going on well and the ph} should be notified at once. Practically all ante-partmn hemorrhages are due to a partial or complete separa- tion of the placenta from its attachment to the Uti wall. This accident occasionally occurs when the pla- 1 occupies a normal position, but is most frequent when it has 1>ecn implanted in the neighborhood "f the internal os — placenta praevia. The most charac- teristic symptom is haemorrhage which usually docs not occur till fcbout the seventh month, although abor- tions at an earlier period arc undoubtedly often due to this condition. The complication il 1 WT) dangi one. If the danger is imminent the nurse may pro- ceed to pack the vagina before the arrival of the phj ilcian.
Convulsions sometimes occur during the pregnant State, and too often are On indications of urcemic poi- toning. All. and more particularly nervous patients, should be allowed plenty of light, nourishing food and gentle outdoor exeni < . and In- kept as free ;i from all worry and excitement. An abundance of pure fresh air is needed, and small over-heated rooms, confinemeni indoors and crowded assemblages are to be avoided. The food should be nutritious and eas- ily digested. Pastry or sue. 1 should be restricted or
XUftStNG
entirely forbidden at they tend to cause acidity, flatu- lence and gastric distress. Water should l>c taken freely; the bowels should be opened daily. The daily bath should be warm but not hot, as the latter is liable to stimulate the uterus too much and thus bring on labor prematurely. In the later months of pre: die patient should give even more attention to details in the care of herself. Rest in the recumbent position for a certain time each >lav is necessai v. As a support a long thin flannel binder should be firmly wound from below upward about the abdomen. For cedema of the legs flannel bandages are sometimes very use- ful. Plenty of eleep is necessary and all excitement is to be avoided.
Certain symptoms precede the onset of labor, be- ginning about two weeks or ten days previous to it. when the fretus descends somewhat into the pelvic cavity; the pressure is now removed from the thoracic organs to those of the lower abdomen, and may cause frequent micturition, constipation or diarrheca ; cedema of the external genitalia and of the lower extremities is sometimes very marked, owing to the pressure on the pelvic veins. The woman often complains of a feeling of numbness, neuralgic pains, or cramps in the extremities and difficult} in walking. The cervix se- cretes a large quantity of mucus, which lubricates the surrounding structures and prepares them for the expulsion of the head. Hie vagina becomes softer; rhythmical uterine contractions come on in the even- ings about 6 p. m. and last until midnight These are not so noticeable in primipara as in multipara. , Labor is divided Into three stages, which practically are not sharply separable in normal cases. The first
LABOR
49'
stage comprises the changes which bring Gtboul pletc dilatation of ilu; cervix; .luting the MCOnd Kage the child, and during the third the placenta is delivered. The dilatation of the cervix is a gradual process: when the pains are first felt it may l>e possible only to introduce the tip of the finger through the os, but with each succeeding pain the bag of waters is pressed down and produces gradual and oven dilatation. When a pain subsides, the bag tends to recede into the uterus, but with each subsequent contraction it continues to press upon the cervix until the tissues are fully re- laxed. During this process the surrounding blood- vessels become congested, Ud the cervix may be slightly lacerated, so that the discharge is tinged with blood. When the external os is three and one half inches in diameter, it it time f'>r the membranes to rupture. The rupture should occur spontaneously, but occasionally it must be artificially produced by means of a grooved director or a sterilized darning needle. After this the head descends into the vagina, a portion of the fluid remaining behind : as the head goes back during the intervals between tin- pains. other portions of the waters come away. This process continues, the pains gradually becoming more vigor- ous, until the waters arc expelled. In rare instances the head may be born without rupture of the mem- branes, and the child is then said to have been "born with a caul." The uterus, assisted by the abdominal muscles, continuing to contract, causes the child to descend, dilating the porta as it goes. Finally, the head comes down upon the- perineum, and begins to dilate the vulval outlet. At this stage a certain- am of support should be given to the perineum during a
492
NUKSIXC
pain, as the head presses upon it, stretching it each time a little more. While the head is being born the perineum should be supported by the hand, the same time the head is pushed upward, thus reliev- ing the strain and lessening the danger of rupture of the perineum, which occurs in from 20 to 40 per cent. of all women pregnant for the first time.
The placental or third stage lasts from the time that the child is bom until the placenta il delivered! dur- ing this period the woman may complain of some disturbance, tuch as chilly sensations, and aftet the removal of the child the filling up of the blood- vessels of the abdomen may cause headache or syncope. Before the placental pains come on there is a period of quiet of from five to fifteen minutes ; then contractions begin again, and the delivery of tin- pla- centa takes place. In a normal delivery the placenta nds folded vertically in the axis of the womb through the vagina; after thirty n if Uterine
contractions do not take place of their own accord, it may be necessary to excite them ; this ma) be done by gentle friction over the fundus. Five or six gentle motions will be usually enough ; if after gentle manipu- lation the Ut< line walls do not contract, the obstetrician usually expels the placenta by what is called "Crcde's method." The uterus is firmly grasped in the left hand, m, 1l1.it an even pressure can be exerted from all sides and from above upon the body, with the result of actually Squeezing out its contents. The best plan is
to stimulate the fundus gently by kneading it until ■
contraction is felt, and then express immediately. Itn-
.tely after the birth of the child, the uterus should
be felt as a firm, round, hard mass, reaching midway
THE PVEkPEA'Al. STATE
493
I ctween the symphysis pubis and umbilicus. The pla- centa usually leaves the uterus in from tea to twenty minutes after the birth of the child and enters the va- gina, whence it is expelled by the action of the ab- dominal muscles, which may occur in a few minutes, or not for hours.
The passage of the placenta from the uterus to the vagina is indicated by the fundus of the. uterus rising up about two inches above its previous position; when this occurs the placenta should be pushed out of the vagina, the uterus being used a* a piston.
Trail ion Oil the umbilical cord should never be made under any circumstances by a nurse. As the placenta is expdled, the membranes may be ran^ht in the os; even now no traction should be made, but one twists the membranes gently to prevent tearing, and waits a moment or two until the spasm of the cervix is over, when everything will come away.
After the delivery of the placenta the uterus presents at the placental site a large raw surface with open bleeding vessels, from which there may be h;< rhagc if the uterus does not contract well. After the • Klivi ry of tl»e child it is essential that one hand In- kept always over the uterus until some time after the placenta is born. Occasionally the doctor will entrust the nurse with this duty. Any relaxation of the uter- ine walls must be carcfullv watched, as there is no danger of haemorrhage Erom the torn placenta] ves- sels so long as the uterus keeps well contracted..
The numerous Iaivrati"n-, small anil large. Of the uterus, cervix, vagina, and perineum make the puer- peral state dangerous, since these are so many open pathways for ir.f •::•>,, with septic material. For this
494
NURSING
reason the same precautions must be taken in treating a patient in the puerperal state as in caring for anv open wound; in other words, the same rigid anl measures should be enforced as in cases of operative surgery.
The nurse should never examine vaginally unless told to do so by the physician in charge of the case. For, if she does, no matter how can-fully she may dis- infect her hands, and the patient has a rise of temper- ature during the pucrpcrium. she is sure to be accused of infecting the patient, even though the doctor may have examined with dirty hands. As an obstetrical case must always be regarded as being strictly surgical in character it is always understood that no nurse who has been recently exposed to any source of infection, such as a contagious disease or has been taking- care i if a septic case shall ever undertake the care of a woman in labor. In fact because her case is surgical such a patient should always be cared for in a maternity hospital where aseptic precautions can be properly car- ried out. There are many other reasons why she is much better off in a good institution, and every effort should be made to induce the women of the poorer classes to avoid the risks they incur when confined in their own homes.
The average duration of labor in primiparac is seven* teen hours, in multipara; twelve hours. The second stage of labor in the former usually takes two hours, and in the latter one hour. Labor pains usually begin in the evening, and the majority of births take place between midnight and 3 a. m.
In primiparous women the doctor should 1>e sent for about six hours after the onset of the pains ; while in
MF.PARATIOS'S FOR LABOR
49$
multiparous women he should be sent for as soon .is llie pains begin to come on at regular intervals.
When a nurse is called to assist at a confinement, her first duty is to see that the necessary articles are ready at hand, that the patient is prepared, and that the room and bed are arranged ; she must also make sure that everything has been provided for the reception of the child. There must be plenty of sterilized hot and cold water, five basins, preferably of china or granite-ware, soap and nail-brushes, ioo Bernay's bi- chloride tablets (four to a pint making a i-iooo so- lution), 4 or. of permanganate of potash. 8 oz. of oxalic acid, 4 oz. of boric acid, sterilized vaseline, one dozen sterilized towels, one sterilized sheet, a sterilized bobbin for tying the cord, plenty of clean towels, a baih thermometer, a rubber sheet, a small old blan- ket or a piece of an old blanket, a large square of old muflin or linen, blunt scissors, ice and a douche-pan. A Davidson's syringe, ergot, chloroform and whiskey may also be required, lint the doctor usually provides these.
The labor-bed should be of medium height, single, and situated so that il is accessible from both sides; a hair mattress is the best, and it should not be hol- lowed out in the middle ; a feather bed should never be used. The mattress is to be protected with a large rubber sheet, and over this a cotton or linen sheet is placed ; next comes a draw-sheet or large sheet folded once, which should be kept smooth and in position by means of safety-pins; then over this are placed a sec- ond rubber sheet and draw-sheet, which may be rc- ed after the confinement with little difficulty, leav fag the patient in :■ dry, comfortable bed. In addition
496
NC'fiS/XG
to these sheets, pads may be prepared to absorb the discharges: the most convenient size is about square and two inches thick: they may be made of cither bran, sawdust, or absorbent cotton, the last being rather more expensive. The cotton may be covered with cheese-cloth; soft old linen or muslin docs very well for the bran-pads, the bran being prevented from becoming lumpy by loosely quilting the pad. These padi may be rendered perfectly clean by sterilization in an Arnold sterilizer for half an hour, or by baking in the oven. When used properly they will absorb all discharges, and may afterward be burned. These pre- cautions can. however, be rendered unnecessary by the use of the Kelly obstetrical pad, which prevents any soiling of the bcd-lincn. In private practice this is Uiuajly provided by the obstetrician.
The nurse should next prepare the patient by giving her a thorough bath, brushing the hair and braiding it into two braids ; the bowels are to be emptied by giving a simple enema, and if the urine can not be voided the patient should be cathctcrized. The external parts should be carefully bathed with soap and water, and then with a i-iooo bichloride solution. The patient is best clothed in a clean night-dress and enveloped in a warm wrapper. Light, niisiimulating, and easily di- gestible food is given, and she is allowed to move about, the room during the first stage, unless there should be a previous history of precipitate labor. A record of the antepartum temperature, pulse, respiration and the time when labor began should be charted. For the first few days after labor the temperature, pulse, and respiration are taken three timet a day and a record is kept of the treatment and symptoms.
TUB CONDUCT OF LABOR
497
The first stage of labor may occupy from 12 to 14 hours. Din in:; the pt-ii-.d the child should he fre- quently palpated through the abdominal walls of the mother, and the fcetal heart counted, as marked changes in it frequently indicate that the child is in danger.
Owing to the danger of infection, vaginal examina- tions should be made as rarely as possible, and then only by the doctor; at least 95 per cent, of all cases can be conducted by palpation through the abdominal walls.
The only information which cannot be gained by palpation is the degree of dilatation of the cervix, and this can be told in great part by the character of the cry to which the putn ression.
Before a vaginal examination is made the external genitalia should be again washed with soap and hot water, and then with a 1-1000 bichloride solution, being afterwards cooled with a towel soaked in the same solution.
The hands and forearms of the examiner should then then be carefully disinfected according to the following rules: Use soap, hot water and nail brush for at least five minutes, or until microscopically clean; soak in hot saturated solution of permanganate wash :>IT in hot saturated solution of M and then soak for
three minutes in a 1-1000 bichloride solution, the hand going wet from the solution to the vagina.
A sterilized towel is then plied In math the but- tocks of the patient, and the examination made under the guidance of the eye, the labia being spread apart by the other hand, so thai 1 1 »< examining finger may- be introduced directly into the vagina, without coining
32
498
NUXS/A'C
in contact with the external genitalia. The examining finger is introduced into the vagina during an inter between the pains, as the membranes arc then lax and the presenting part of the fietus can be defined more easily; but if one wishes to determine the extent of tl>e dilatation of the os. it is well to examine ul •• during a pain, as the outline can best be felt when the membranes arc pressed against it. Every examination should he made gently and carefully in order not to rupture the membrane*. The patient should be cau- tioned not to bear down during the first stage, as this only exhausts her without doing any good. When tin- os is fully dilated and the pains begin to follow each other in rapid succession, she should be put to bed, a large sterilised sheet having been previously pinned about the hips, while the night-dress is folded neatly and smoothly up under the arms and fastened in place with safety pins. This prevents any soiling of the night-dress, and the necessity of changing it when the labor is over may thus be avoided, r-
When in bed the patient usually lies either on her side or on her back, but preference is given to the dorsal position.
Tin' expulsion of the head causes the most pain. and as long as it is advancing satisfactorily it is not considered wise to interfere. At this stage the pa- tient is instructed to bear down. A long strap or tow el fastened to the foot of the bed for her to pull on is of material assistance. If. however, the head has been down upon the perineum for two hours and no pro- gress has been made, the physician usually takes steps to terminate the labor. It is in this stage, when the pains arc too strong, that chloroform is administered
THE COS-DUCT OF LABOK
499
in small doses, since the use of it calms the patient, weakens the pains, and prevents the too sudden expul- sion of the head. Gdoroform should never be given in the third stage of labor.
The most desirable presentation is that of the head. Any part of the body may present, and it is particu- larly important that the obstetrician sec the case early, since sometimes a faulty position may be rectified be- fore rupture of the membranes has taken place — a thing which may be impossible later. Wc arc speak- ing here almost altogether of a normal labor, in which the occiput is the presenting part, and shall not refer to the cases in which another part, such as the face, breech, foot, arm, or shoulder, presents. These pres- entations will be found fully described in the text- books on midwifery, and it is important that a nurse who attends labor cases should make herself con- versant with many more facts and details about the subject.
If the cord is prolapsed, efforts should be made to push it back carefully above the head, as there is danger that it may be compressed during the pa Of the head through the vulva, and thus the supply of oxygen to the child DC CUt "IT. The nurse's hands having been carefully disinfected the patient should be put in the knee-breast position and the cord then pushed up beyond the head into the uterus. The phy- sician should be called promptly. After the hod is born there is usually a slightly longer interval before the next pain ; the nurse immediately wipes out the eyes and mouth of the child with pledgets of absorbent cotton soaked in a saturatol solution of boric acid. The shoulders arc born at the next pain, and with
XL'KS/XG
them, ai a rule, tin? whole body. The shoulders in iluir passage, perhaps almost as frequcntK U head, produce laceration of the perineum.
A* soon as it is born the child is usually placed on its right side; the old idea was that tin 1 in the
closure of the foramen ovale. If the child does not cry or make some sign of 6 »l once, it should be slightly shaken and a finger inserted into its mouth to remove any accumulation of mucus. A gentle slap on the back may excite inspiration, or a few drops of cole! water sprinkled over it briskly with the fingers will often cause the child to give a cry. If these means arc not successful, tickling the ribs in the region of the dia- phragm acts as a strong stimulant to the respiratory centre, or a few drops of whiskey or brandy rubbed into the skin will generally be found efficacious. If. however, they fail, artificial respiration must be insti- tuted.
Unless the child shows signs of asphyxia, the cor should not be cut until pulsation in it has ceased, or i any rate not until the child has cried. The cord be tied in two places, the first ligature being plact about one inch from the child's abdomen, and the sec- ond about two inches farther away; it is then divic with scissors at a point midway between the twe • times it is tied in only one place, but the second ligature should always be used as a precautionar measure to prevent haemorrhage from the placenta, or
ling of the bed. Moreover in case there were a ond child still in the uterus the loss of blood migh otherwise be fatal to it. The cord should be examine for haemorrhage about four times during the first hoi or two.
THE CONDUCT OP LABOR
JOI
The child should he at once wrapped in a large square of old muslin, and again in a flannel Maul;.!, and laid in a warm place until llic mother lias been at- tended to; she should receive the first care unless there is difficulty with the child's breathing. After the birth of the child 1 in hand should I"- applied to the
fundus of the uterus and kept lh< re continuously. As long as it remains firm and hard there is no danger of hemorrhage; but if at any time it tends to relax, be- coming soft and flaccid, it should be kneaded vigor- ously, so as to stimulate uterine contractions. But as long as the uterus is firm and hard, kneading is not only unnecessary, bul absolutely harmful, as it inter- feres with the normal separation of the placenta from the uterine wall. For half an hour after tin exptl
of the placenta the condition of the uterus should be
watched in the same way. If it is necessary to give ergot at all. this is the time, but this drug should never be given until aftei the of ih< ■ p!.:ei ma. Tin
latter should be kept in a covered dish until the physi- cian has had tune to inspect it. If any portion of the placenta is missing, the physician will seek to remove it, as retained portions are liable to decompose in the uterus and he a direct source of danger. The safest way to dispose of the placenta is to wrap it in papei and burn it ; or it may be buried
The external genitalia should now be thoroughly cleansed with a 1-1000 bichloride solution; a sterilized napkin made of absorbent cotton and gauze is put on and the soiled bedding removed. The dressing is changed once in three hours for the first twenty-four hours; after that once every four or -.i\ hour'; is all that is necessary. The nurse should remember tn-.cr
|M
JVUXS/XG
to do this dressing, calhelerize her patient, or care for ktr after a movement of the bowels, without first thor- oughly cleansing her own hands and toting every anti- septic precaution possible. If a binder is used, the most comfortable will be a Scultctus bandage, as any degree of pressure desired may be made with it : held in place with the perineal straps. In lieu of the Scultetus an ordinary roller towel, pinned on firm- ly with safety pins, can be made to answer every pur- pose. Sometimes extra pressure is made over the uterus by means of a folded towel placed under the bandage. The use of this depends, however, entirely upon the wishes of the physician : many do not employ such a pad, owing to the fact that it frequently be- comes displaced, in which case it does more harm than good. After the patient has been bathed and cared for. she should be kept very quiet ; no talking should be allowed, and visitors, even members of the family, should not be admitted to sec her until after she has had some hours of rest. A constant watch should be kept upon the pulse, which at this time will have fallen to or even below its normal level. An unusually rapid pulse, such as one of too or more per minute, unless it can be accounted for by some other known cause, may be taken as indicating the occurrence of haemorrhage. These "post-partum haemorrhages" form one of the greatest dangers to be encountered after the birth of the child. The haemorrhage may come on quite unex- pectedly, and it is necessary to be always ready to meet this emergency and to take prompt measures to check the bleeding. The means l>v which nature endeavors to prevent post-partum haemorrhages arc contraction and
POSTPARTUM HEMORRHAGE
5°3
retraction of the uterus ; the sinuses are thus closed ami the venous blood-vessels are occluded.
The best thing to do, and the one which can be done most quickly, if haemorrhage occurs, is to induce con- tractions of (Ik- uleras by grasping the fundus and employing a firm but gentle kneading, pressing down- ward : the foot of the bedstead is to be elevated, and some form of ergot may be given hypodermically ; ice may be introduced into the vagina or very hot douches given, and the patient should be kept quiet. If these procedures fail, the hand and arm should be sterilized and introduced into the uterus, and the blood-clots re- moved; at the same lime stimulation of the internal surface of the uterus with the finger-tips usually causes immediate contraction ; the danger in doing this is that infectious material may be introduced unless the hand is rendered surgically clean. Perhaps the safest and most effectual method is to inject very hot water (1200 F.) through a long douche-nozzle directly into the uterine cavity. Sometimes astringents may be intro- duced in the form of lemon-juice, or vinegar, which can always be procured. This emergency, perhaps more than any other, requires presence of mind and prompt action, and no time should be lost in making every effort to control the hxmorrhagc. After we have been successful in producing contraction of the uterus, a rubber bag of cold water may be placed on the abdomen above the symphysis pubis to prevent sub- sequent relaxation. Cerebral anxmia and faintness from the enormous loss of blood may follow such a hxmorrhagc. The symptoms and treatment arc the same as those given when discussing hxmorrhage as a rica] emergency.
NURSING
The pturptrhtm begins as soon as the placenta is de- livered. Marked changes must take place in the uterus before it can return to its ordinary quiescent condition. Immediately after labor there is a period of comfort and relief, which may be followed by a ]>ost-partum chill of more or less intensity and of shorter or longer duration ; this is not of very great importance, as after the bifth of the head evaporation from the skin and lun.: taki place, producing chilly feelings, which
soon disappear after the patient has been made de and comfortable. The temperature of multiparous pa- in in. maj rise Erom I to rj^° F. in the puerperal state, and there may be a temperature of 99.5' I", without the case being abnormal. This elevation is supposed to be due to organic disturbances which take place in the uterus, lacerations of the cervix or vagina, or nervous influences. The pulse falls after labor, ranging be- tween 60 and 70, and on the third day may go even as low as 40. Frequently this condition is associated with diminished arterial tension, but its cause is imperfectly understood.
The skin, which Jn a most active excretory organ, is constantly exposed to sudden changes of heat and cold. It is best not to cover the patient too warmly, but she should never be exposed to draughts, particularly if she be a nervous woman. The urine will be abundant. and not infrequently a trace of sugar appears in it. If the milk in the breasts is used up as rapidly as it forms, the sugar disappears. Retention of urine is a very common occurrence after labor, and is due to the previ- ous overstretching of the bladder, and also to a want of elasticity in the abdominal muscles, which fail to
assist the organ in it- action. The loss of the contents
THE PUERPERIUM
5°S
of the uterus makes the entire weight of the body lea by one-twelfth than ii was before.
Involution, or the process by which the uterus re- turns to its normal condition, begins with the after pains and COIttinuei for from six t" eight weeks. Tin- change is gradual, and the normal size and condition arc slowly attained, fatty degeneration of the muscut&I fibres taking place. As a result there is a considerable decrease in the weight of the uterus. The cervix qoicklj regalni Its normal site; ;n Brat it la soft and flabby, but two weeks after labor it should be about normal. The vagina is at first smooth and Kitted the third week it becomes much mttUer, the change being more marked near the outlet than internally.
When involution is incomplete and the uterus re- mains larger than H ought to be, we have the condition nbinvolution." This maj often be traced to getting up too early after labor, and is a frequent m Hirer "i trouble to wORien WHO Ii.im bomC ehihlicn.
After-pains are due to contractions of the uterus, and resemble somewhat labor-pains, The) cause the expulsion of blood-clots, and usually continue from one to four days. If labor is of short duration, the after-pains tit intense and prolonged, rind nee versa; in multiparas they arc apt to be more si sen- than in prhniparse. If they trouble the patient too much, they may have to be controlled by small doses of morphin.
By the lochia we mean the discharges from the ute- rus and soft parts after labor. At first these discharges are mixed with blood (lochia rubra), and contain dark coagula. n hi dl of placenta, and pieces of
From the end of the third to the sixth
ATUA'S/XG
day they arc paler in color {lochia serosa) ; they contain !■•■;> Li. mil and mure serum, and epithelial oclli from the cervix and vagina, besides portions of membrane. The lochia after this assume a yellow-greenish color and contain pus and fatty cells, with a small quantity of blood. By the fourth day bacteria arc plentiful and die discharges have a decided odor. The lochia vary in amount i" different individuals; in those who men- struate freely and do not nurse their children they are usually copious.
The breasts on the third day are frequently swollen and very sensitive to the touch. Sometimes swelling and tenderness in the glands of the axilla-, with chilly sensations and elevation of temperature, are noted. This was formerly thought to be a physiological pro- cess, and was called "milk fever," but is now recog- nized as being due to some form of infection. The colostrum is the first milk secreted: as it comes from the breasts this is a semi-opaque fluid which contain! ■ large quantity of sugar and organic salts. It coagu- lates on boiling and is said to have a laxative quality, driving out of the intestines of the child the meconium or waste material which they contain at birth.
The characteristic symptoms of the puerperal state are, then, enlargement of the breasts with well-marked areola? : the uterus is enlarged ; the vagina and vulva are swollen and avlcmatous; there is a Iochial dis- chargc, and as a rule more or less laceration of the cervix. If, after the first eight or twelve hours, the patient has not passed any urine and other means have failed, the catheter must be employed, absolute cleanli- ness of the parts hcmi: observed. The diet at first sli.nild consist of liquid, unstimulating food, given in
THE PUERPERIUM
507
small quantities and at frequent intervals. If the baby is not to be nursed the amount of liquid is rest! i On the third day light diet, such as boiled eggs and milk-toast or custard, may be given, and to this may gradually be added chops and cooked fruits, as the latter will aid in keeping the bowels regular. If there be any tendency to constipation (and this is usually the case), the bowels should be opened by a simple or a glycerine enema or by one or more doses of the compound liquorice powder, about 2 drachms, repeat- ed, if necessary, after three or four hours; or half a glass of Hunyadi Janus water may 11. or half
an ounce of castor oil.
The nursing of the child should be begun as soon as the mother has rested and recovered from the exhaus- tion, as the stimulation of the breasts by acting rerlexly helps to bring on uterine contractions. The breasts lx-fore .iml after confinement .should have special at tention : they arc to be bathed with alcohol and boric acid night and morning, during the two or three months previous to labor, m order to harden the skin. If the nipples arc very sensitive, they may be protected with glass-bell nipple-shields. Before touching the breasts antiseptic precautions should lie observed with the hands, and the nipple should be carefully bathed, before and after every nursing of the child, with a 5 per cent, solution of boric acid, with which the child's mouth should also be washed out before and after feed- ing. The patient should be warned t<> handle her breasts herself as little as possible and only when her hands arc quite clean, as there is always danger of introducing foreign material through the nipple opening, or, if there should be a fissure or crack
508
NURS/XG
on the nipple, infection may take place through it — ;ui accident that too often results in an abscess of the breast A crack or i on should be bathed with
a 5 per cent, boric acid solution, then painted with a 2 per cent, solution of nitrate of silver and afterwards with the white of egg. Iftlubn: very full and
hard, the quantity of milk -o reted may be reduced bj means of a breast bandage applied with even pres- sure. Care .should Ik- taken to keep the breasts soft and pliable by not allowing the deeper glands to re- main unemptied,
Tin lying-in period usually lasts until after the lochia have stopped; by this time no pain is fell in Ma- back and the patient is not easily exhausted. This takes from ten to fifteen days, or even longer. During the first ten days the patient should lie down all the while. Visitor! ibould In- admitted only by permis- sion of the physician and never more than one at a time. The hygienic arrangements and care of the room must be as perfect as post
Some of the suspicious symptoms during the puer- peral state are a rise of temperature, a rapid pulse, a flushed face, a chill, pain and tenderness of the abd men, an abnormal increase or decrease of the lochia, hemorrhage, or, finally, an offensive odor of the dis- charges. At each change of the napkin the amount of the lochia, their color and odor, should always be noted, and if the discharge presents any unusual ap- pearance, the napkin should be kept for the doctor's inspection.
< feral Fever. — One of the most grave conditl ins which can occur during the puerperal star wn
as puerperal fever: this re lilts from a septic infection
THE rt ■/■: urn a- /r m
509
which has taken place during: labor or the lying-in period. Every ohm «f puerperal fever arises from the
introduction of infectious material into some wounded portion of the genital tract. The modes of infection are two in number: first, the septic matter may he carried In on (he Rogers or instruments, and in mis v. ;iv physicians and nurses may be the agents of con- tamination. The second mode of entrance is readily
understood when we remember the almost constant presence of bacteria In the cervical and vaginal
turd and in the pubic hair. The nurse should see t<> it that this dreaded complication never occurs from any carelessness or lack of precaution on her part,
If called upon to nurse a case of puerperal fever, besides carrying out faithfully the treatment outlined
by tin I'livH-iaii, the nurse should do everything in
her power to improve the patient's general condition.
1 In woman should be kept thoroughly clean — she
should be given plenty of fresh air to breathe, and her
linen should In frequently changed. In addition t& these attentions the nurse should see that the patient
has a liberal suppi) of nourishment
A septic phlebitis resulting from a thrombosis of the femoral vein is a not infrequent complication. The patient may first complain of pain in the D( ighl>orhood of the groin, which ii soon after followed by swelling of the foot and leg. Absolute quiet ia to be insisted upon. The leg is to be wrapped in cotton-wool, ban- 1 and elevated. In such cases massage ia ret] dangerous, because the immediate danger lies in the
fact that a portion of the blood elol becoming In
off may be carried into the circulation and lodge ill
5io
NURSLVC
one of the vessels of the lung, causing pulmonary em- holism and sudden death.
Eclampsia Is characterised by convulsions that may occur in pregnancy, during labor, or later in the puerperal period. They may be clonic or tonic. In the majority of cases, although not in all, premonitory Symptoms announce the impending outbreak. Of these the most important arc headache, vertigo, an unusual desire to sleep, flashes of light before the eyes, nausea, oedema of the face and extremities, dis- turbances of the memory, gloomy forebodings, and finally, the most important, the presence of alii and casts in the urine.
The attacks may resemble somewhat those of epi- bul the civ El lacking and the facial contortions arc far more hideous. When they occur during lal*>r, the first one is often preceded by a short period of calm, in which the patient ceases to complain; she closes her eyes and seems to be asleep; the pulse becomes small and the respirations shallow. Then the convulsive seizure comes on, commencing in the muscles about the eyes and extending to those of the face and limbs. The superficial veins arc swollen, the eyes become blood-shot, and the skin everywhere shows a marked degree of cyanosis. Involuntary evacuations may occur. On awakening from the at- tack, the patient complains of headache, impaired mem- ory, and pains in the muscles. The body is often covered with a cold, clammy sweat. Too often the patient lies in the first attack, or convulsion follows convulsion with lightning-like rapidity till death oc- curs from sheer exhaustion. During a convulsion a wedge should be placed between the teeth, to prevent
ECLAMPSIA
5'
laceration of the tongue. As little restraint as possible should be used. Chloroform may be employed when the convulsions follow in quick succession. Infusions of saline solution should be given and the bowels moved freely. Free perspiration should be induced. As soon as the patient CU -••wallow she should be made to drink water freely.
Eclampsia predisposes to ]>ost-partum hemorrhage and to puerperal inflammations. In fatal Cases death results from asphyxia, due to spasm of the respiratory muscles or to exhaustion of the nervous system, i from the direct effect of the anemic poisoning or from the continuous muscular exertion. The earlier the convulsions occur, the more unfavorable tin pi It is very rare for the convulsions, if they appear during pregnancy, to cease previous to the birth of the child. Under such circumstance! half the children are born dead. The routine examination of the urine of pregnant women is an indispensable precaution.
Albuminuria calls for special treatment. The utmost care should be taken to avoid all mental excitement, anything which would interfere with the digestion, and sudden variations in temperature. When there is redema of the limbs and face a strict milk diet will be enjoined and suitable medicinal treatment will be or- dered by the physician. The action of the skin is to be promoted by means of the wet pack, and the bowels should be kept freely opened by laxatives.
Puerperal Insanity. The insanity which sometimes occurs during the puerperal period generally takes the form of melancholia, although genuine mania is not uncommon. In the treatment the rally arc
to check exccssi.ve discharges, support the patient's
$U
XVttS/.S'G
strength, and ensure perfect quiet and freedom from mental irritation. Upon the appearance of the first sign of this complication the child should be taken from the breast and the patient put upon a liquid diet. The bladder ami rectum arc to be emptied at |>n '[><■! interval.-*, and attention should be paid to the regulation of the heat and light of the room. The skin is kept active by sponging, and the sacrum watched carefully for the appearance of bed-sores. All pic- tures or articles of furniture in the room which seem to disturb the patient must be removed. Dr. Willia T. Lutk >.-.;. I that he knows of no other condition in which a trained nurse can be so valuable. She must see that the patient is kept covered, that she docs no injure herself, and that no member "f the family is allowed in the room. Above all. the nurse must gair the confidence of her patient and try to keep her tpiic without using force.
Cold to the head is effective for the severe headache which will often be complained of. The patienl never be allowed to get out of sight, and, above all. the mother and child should never be left alone together for a moment, as a suicidal or infanticidal tendency is usually present. During convalescence, rest and sleep, nutritious food and daily evacuations of th bowels arc factors which hasten a returu to health.
CHAPTER XXVII.
Disorders of the Special Senses.— Nursing in Diseases or in iiroat, Nose and Ear.
The special anatomy and physiology of the organs which have to do with the special senses and their relation to other pans of tin: hody must be included in the general course of training, in order that the nurse may be able to carry out orders intelligently when dealing with the various disorders which affect these most important functions. Moreover, in her work in hygiene she will be taught how many of these diseases, which often entail very serious consequences, can be prevented. With congenital or acquired defects af- fecting the special senses wc shall not deal here, but shall confine ourselves to pointing out briefly some of the nurse's duties in diseases of the eye, throat, nose and car.
Diseases of the Eye. — Pain, redness, heat, sometimes swelling and more or less impairment of function are usually among the first symptoms in diseases of the eye. A condition of fatigue of the muscles of accom- modation is very common and is generally associated with redness of the lids or conjunctiva:, pain in the eye and a more or less diffuse headache. If the con- dition is due merely to over-strain, it can readih be relieved hv rest, hot or ■ M ^plications, and massage. If, however, it is of frequent occurrence and comes on very readily the patient should consult an oculist, as in
33 513
5'4
Xl'fiSWG
many cases sonic degree of astigmatism or some other lefed exists, which can be remedied by the wearing (if proper gla-
The term ophthalmia includes all inflammations of the conjunctiva' and should not be applied to other dis- eases of the eye. Purulent ophthalmia in infanta in commonly called ophthalmia neonatorum and has already been described in the chapter on diseases hildren.
The treatment consists in keeping the eyes free from the poisonous material. To effect this frequent wash- ings or irrigations with a sum lution of boric acid are employed. Tor the pain a solution of cocain is sometimes ordered. For the discharge solutions of nitrate of silver arc sometimes Ordered : these must not be used by the nurse except under the direction of the physician.
If. as more often happens in the case of adults, only one eve is affected, the well eye should be pro- tected by means of a Bullcr shield, which can be made as follows: Take two piect '^ ni india-rubber plaster one 4 inches, the other 4jj inches square. Cut a round window in the middle of each. Stick them together after having inserted between them in the window a : in ill w.itch-glass. The plaster is fastened In its free 1 order and by other strips to the nose, forehead and check, the lower outer angle being left open for ven- tilation. Through the glass the patient can sec and the eye can be kept under observation.. The st; precautions against conveying the infection to the sound eye of the patient and to those of others mus be liken. The nurse must touch her face with her hands as little as possible, and then only after Ik
OPHTHALMIA
5'5
hands have been thoroughly disinfected. All dress- ings should be burned or soaked in a i to 500 bichlor- ide solution, and then boiled. As the disease is ex- hausting rest in bed and a nourishing did IK helpful.
Muco-purulcnt ophthalmia occurs as an acute dis- ease especially in spring and autumn. This form of conjunctivitis is often popularly termed "pink-eye." It generally runs its course and terminates favorably in about two weeks. There is great congestion ; the pa- tient feels as if grains of sand were sticking under the lids, and there is a more or less free muco-purulent discharge. The cornea rarely suffers. The diset contagious. Mild antiseptic lotions arc employed, and cleanliness ami hygienic surrounding* hasten the re- covery.
Various forms of conjunctivitis are often as- sociated with the exanthematous fevers in children, especially measles, and need careful attention.
Granular ophthalmia, trachoma (or "granular lids") is relatively common among children, and also among adults, especially in the families of Russian immi- grants. To the usual signs of conjunctivitis are added the presence of masses of granules — the "sago-grain" or •'follicular" granulations. The • .nta-
gious and no child affected with it should be allowed to attend school. Dirty surroundings favor the spread and duration of trachoma. General hygienic treat- ment is all important. Astringent and cleansing solu- tions arc employed ami the lids are everted and painted with strong solutions of nitrate of silver. Copper sulphate (blueStOne) is preferred by many oculists.
Iritis, or inflammation of the iris, is usually due to syphilis or rheumatism, but may result from wounds
j. 6
.VUffS/.VG
and other injuries of the cornea. The color of the membrane changes, and its textures show a kind of
"muddiness." Adhesions between the posterior sur- face and the capsule of the lens are apt to follow. There is severe pain, the movements of the iris are diminished and there is more or less photophobia. In these cases the physician usually orders the instillation into the eye of a few drops of a solution of atropin (atropin. sulph. grs. iv. An,. \\). This paralyzes the muscle and puts it at rest.allowing the pupil to dilate. In addition to the atropin applications of hot water arc generally grateful and sometimes leeches are applied over the temple.
In glaucoma, where, owing to pressure within the eyeball the pupil is dilated and fixed, or when a foreign body or an injury has produced an iritis, iridectomy — the cutting away of part of the iris— is often per- formed.
Cataract, or opacity of the crystalline lens, in most cases occurs in elderly people. When ilk- j complete — or in common parlance when the cataract is ripe — it has a milky white appearance and can be extracted as a solid body. After removal of a cataract, a bandage is applied and not removed for a week. The patient is kept quiet in a darkened room and only light diet is permitted. In younger individuals, or in other patients when the cataract does not ripen and be- come solid, dispersion is brought about gradually by "needling."
Strabismus or squint is due to a want of balance in power between the opposing muscles which should hold the eyeball in position. Some forms can be relieved bj impropriate glasses and exercises. In other cases
BYE AFFECTIONS
5»7
tenotomy — the cutting of the muscle — is resorted to. A sty is a boil or abscess Which forms at the root of an eyelash. Bathing with very hot water — every hour or so — will relieve the pain and hasten suppuration.
Eye affections sometimes occur as complications in various infectious fevers — particularly measles. In such cases prompt care may prevent serious later con- sequences. Hot applications of a boric acid solution (a tcaspoonful to a glass of hot water) relieve plfn and keep the eye clean. For injuries to the eyes hot and cold applications are employed. 'Hie former arc used for infections of the cornea, the latter — in the form of iced compresses — for hemorrhage and dis- coloration.
For the induction of local anesthesia for operations upon the eye cocain is used almost exclusively. The solutions (4 or 5 per cent.) should always be freshly made. In order to obtain total insensibility to pain, for 15 or 20 minutes before the operation a drop should be instilled into the eye every three minutes. During the intervals the eye is kept closed and a pad placed over it.
For assisting the surgeon during an operation on the eye or in the after-treatment the nurse must cul- tivate a light and skilful touch. The ordinary dress- ings arc very simple — sterilized gauze pads, sponges, adhesive plaster and bandages. The applications used in disorders of the eye come in the form of lotions, ointments, various solutions to be dropped into the eye, chiefly for their astringent or soothing effects and boric acid solutions or normal salt solution for cleansing purposes. In order to paint the inside sur- face, the lid must be everted, a small camel's-hair
5,8
NURSING
brush being employe 1 Ebl making the application. A room for ophthalmic patients should be kept well ven- tihtcda and as a nilc should be well lighted, the eyes
protected b) bondages, Mark gla-vses and green
shields. For patients suffering from photophobia,
however, the room should be darkened and the eyes
should never be exposed suddenly to a bright light.
Affections of the ear, throat and nose can conveni-
be considered together since the causative fac- tors are often directly or indirectly the same. Thus adenoids and catarrh of the nose and throat often lead to disease of the middle car and sometimes to deafness, since the morbid process extends upward through the Eustachian tube. Tor this reason the proper care of the throat is most important in Health and disease. The importance of the removal of ade- noids and enlarged tonsils is now generally appre- ciated. The after care .mi its in the use of sprays, light diet being given for a few days and the general comfort of the little patient being provided for. For
1 operations on the nose the surgeon will give directions suited to the particular case. The hygienic treatment of the ear in health is negative rather than pi isitave. It is never well to do too much or to be med- dlesome. It has been wisely said "Nothing smaller than the end of the little finger should ever be put into hi ( ir," and nature provides normally for the ren of wax from the inner part of the car by the action of the lower jaw during mastication. Children'* ears should be protected from exposure to very severe cold winds, very cold water and draughts. After the bath tlic car should be carefully dried with a relatively large pledget of cotton twisted on a stick.
DISEASES OF THE EAR
5'9
In various disorders of the car syringing is often ordered. This would seem to be quite a simple pro- cedure, but needs i ne properly. A rubber ear lyiinge is often employed, but for thorough irrigation a douche bag serves the purpose much better. The patient is seated and protected so that his clothes will not get wet. The ear to be treated should be in a good light. A special kiiliRv-.-hapo! hasin is held close to the nock just under the car. The lobe is then drawn upward and backward to straighten the canal and a warm normal salt or boric Mid M>fatioa is al- lowed to run in, the bag being elevated only suffi- ciently to allow of a gentle flow with but little force. The nozzle should always be pointed towards the upper pari of the canal, so that the fluid will flow over the drum-head and not directly against it. Syringing of the ears is ordered when a purulent discharge is present or for the removal of foreign l>odies or wax. After the s\ ringing is finished the external portion of the canal is dried with rbent cotton.
Earache is a symptom which always warrants seri- ous attention. It occurs very frequently in children and is often associated with wry high fever and gen- eral constitutional disturbance. Until the physician arrives the application of dry beat externally in some form — hot flannels, a hot-water bag. a Japanese hot- box, or a hot salt bag — is often efficacious. Moist heat in the form of warm compresses or poultices is sel- dom ordered. The patient tbould be given a hot foot- bath and a cathartic. Some physicians order that a few drops of a solution of atropin (grs. iv to water Si) or laudanum and sweet oil should be warmed and dropped into the car with an eye-dropper. A small
5«>
1WRSING
pledget of cotton is then inserted to absorb any ex- cess of fluid, but is not to be left in long.
In cases of suppurative otitis media irrigations with warm saturated solution of boric acid arc usually Jered. Powders may be blown in through a quill hut they are now rarely used, as they are liable to cake and then dam up the discharge.
The Skin. — In addition to its other functions the skin is the seat of the special sense of touch. In cer- tain forms of nervous disease feeling is partially or entirely absent. Thus some patients can be pricked with a pin or bumed without experiencing at tlte mo- ment the slightest inconvenience ; on the other hand in certain affections the skin is so sensitive that the slight- est touch amounts to torture.
Diseases of the skin arc either the result of consti- tutional disorders — of which they then constitute mere- ly a symptom — or arc the result of an unhygienic con- dition of the skin itself. For the nurse, the recogni- tion of certain eruptions — such as the rashes of mea- sles and scarlet fever — is very important, as the spread- ing of •.::>■' di* '■■-' ■ li mm h i «■■■ a ted bj »nj delay in the isolation of the patient. Among the more common skin diseases encountered in infancy and child- hood are: eczema, erythema, scabies, ring- worm, boils, urticaria and pediculosis. In adults skin erup- tions molting from syphilis and nervous disorders are often met with. In children very many skin disorders can ultimately be traced to lack of hygienic surround- ings and improper food, so that besides the local or constitutional remedies ordered by the physician, the treatment consists largely in cleanliness, proper food, fresh air and sunshine. For the intense itching that
DiSSASSS OF THE SKIN
$U
is so frequently an annoying symptom in skin diseases, saline cathartics are sometimes ordered, the areas are protected from the irritation caused by clothing; soaps arc prohibited and soothing lotions, ointments and bath* containing alkalies, such a* sodium bicarbonate or borax, or bland substances such as bran or starch. arc employed. Before a scries of mercurial inunc- tions is begun the patient should always be given a warm bath.
In cases of eczema scratching can be prevented by controlling the hands or arms so that they cannot reach the affected areas. For instance, in cases of eczema of the face or head, padded splints may be applied to the elbows.
Ringworm is very contagious; it usually apprar- on the scalp, but the skin of any part of the body may be invaded. Whatever the treatment ordered, it should be vigorously carried out even for some time after all ligiu of the disorder have disappeared. The part affected should be well washed with warm water before ointments are Applied
In urticaria, or lures, the vasomotor nerves are af- fected. The skin is covered with wheals and there is intense itching. Tbe disorder is often due to indi- ion caused by certain articles of food — in some people more especially by strawberries anil shell-fish. Attention to the diet, saline laxatives, alkaline baths and avoidance of worry are indicated. The disease is sometimes very persistent and recurrences are fre- quent.
Herpes Zoster, popularly known as the "shingles" is due tO inflammation of one or more nerve seg- ments in the spinal cord. First a severe burning or
pi
MKSIb'G
smarting is present ; this is followed by an eruption of vesicles which have the same distribution as the cu- taneous nerves. The most frequent seat of the erup- tion is around the waist (hence the name zona, a gir- dle) following the distribution of an intercostal nerve. The disorder is most frequent in spring and autumn, when the weather is variable. The neuralgic pains are sometimes so intense that the use of morphin becomes necessary. Locally anodyne ointments are employed and general tonic measures are indicated.
For bruises or subcutaneous harmorrhages the local treatment consists of hot or cold applications, evaporat- ing lotions or compresses of olive oil. The discol- oration usually yields more quickly to the last remedy.
Finsen Light. — For dealing with superficial skin le- sions Finsen of Copenhagen first introduced the ac- tinic or light cure. He employed both sunlight and electric arc rays, the heat rays being eliminated. For therapeutic purposes the Finsen method has largely superseded the Roentgen rays. An intense white light is supplied by a high hanging lamp to which a tele- Kope-like apparatus is connected. Through the latter the light is directed upon the affected part, a small area being treated at each sitting and a round piece of glass being adjusted snugly over the spot. Except for some slight inflammation and soreness the process is pain- less. Healing in cases of lupus is very gradual, a daily treatment of an hour being continued for from five to nine months. The chief disadvantages are the cost of the apparatus and the large number of expo- sures necessary ; but already an improved and much cheaper apparim \i.<- !»m invented by a Frenchman which prumi-i ■-. to he a success.
CHAPTER XXVin.
Nursing in Nervous Diseases and Insanity.— The Rest Cure.— Massage.— Elect ricitv.
The nervous system forms an integral and most im- portant part of the human body. Hence it naturally follows that, since the nerves receive their nutrition as do other parts, any disturbance in another bodily- organ is reflected to a greater or lesser extent upon them and we have manifestations which show us that the patient is "nervous." Sometimes, it is true, the central nervous system seems to hear the brunt of the disorder, so that a patient whose ordinary bodily func- tions seem to be working satisfactorily and who is perfectly sound in other respects may lose all power of self-control, may act and talk irrationally and in fact may be temporarily or permanently insane. Thus we have an endless variety of gradations between two ex- tremes— one characterized by a slightly increased mi tability in a patient who is Buffering from SOON slight ailment, the other represented h\ I condition in I the brain has become so disordered that the patient can no longer be held responsible for his tlmu^'l or actions. The latter class of patients is usually found in sanatoria or asylums ; and it would certainly be well if every nurse could spend a few weeks in a good institution of this kind in order to round off her studies for general work ; for putting aside the EflM t that in a general hospital many patients dur-
5*4
XC/f.S/XC
ing delirium arc irresponsible and violent and that nervous and even insane patients arc not infrequently admitted, at least temporarily, there is no doubt that the best nursing is impossible unless the mental no than the physical condition of each patient is taken into rarffttl consideration. And I believe that by a study of this kind a nurse could be impressed better than in any other way with the fact, that the irritability, ex- citability, unreasonableness and most of the trial our patience that arc associated with the taking care of sick persons are to be regarded merely a* syi of disease, to be treated accordingly and to be met with kind, but no less judicious measures than those ac- corded to a patient suffering from severe bodily pain. It is a matter of regret tliat. largely on account of ig- norance in this respect on the part of the nurse, ner- vous patients in general hospitals sometimes meet with real unkindncsv Thus various symptoms belonging to neurasthenia or hysterical conditions arc treated by the nurse as being merely foolish and unworthy of any serious attention, whereas the one thing needed by the patient! is an appreciation of their sufferings and a .mpathy. A nervous patient who thinks that the nurse does not understand or makes light of her sufferings can receive only a minimum of benefit from her care. For neurasthenic and hysterical patients arc genuine wB&tn, although their pains arc not necessar- ily to be relieved by medicines alone. In the nursing of such patients the ethical qualities of the nurse are all- ImpwtaOt, •i"1' •• remains for her to supplement the measures ordered by the physician by a certain well- systematized and patient moral treatment Among the most common so-called functional ner-
NERVOUS DISEASES
5*5
vous diseases that every nurse must meet with in the hospital or in private practice arc neurasthenia and hysteria, both of which conditions are often associated with insomnia. Among the disposing causes arc an inherited unstable ncivnns It-mpci ;u 1 k-iii . shock, UU iety, over- work, continuous over-excitement, lack of proper nourishment and unhygienic surroundings.
Again, these conditions are sometimes associated with definite organic disease. Nervous exhaustion in men may be the result "f excessive brain wear, con- tinuOUl care and responsibility, mental strain from anx- iety and business difficulties aggravated by irregular habits or inattentions to the rules, the observance of which would tend t6 keep the body healthy. In women nervous prostration frequently results from lack of con- genial work, too great indulgence in gaiety or the bur- den of so-called social duties which becomes too great when Ittptf&dded tO the strain of family cares. Nor is it surprising that when one woman endeavors to perform multifarious duties — any one of which would afford sufficient occupation a breakdown Of the ner- vous system, if not some form of insanity, should re- Milt.
Hyttt fa '■■■ ■■< nervous disorder characterized by more or less frequent emotional outbursts often associated with motor disturbances. The patient is sometimes gay. (TiOrC often depressed and is capricfOOl in her tastes and very uncertain. Abnormal sensation often complained of Some patients feel as if there was a ball in the throat — the globus hystericus — which moves about but will nol stay Dp Or down. Others complain of a loss of feeling in a limb or in a whole side of the body. Some patients cannot stand or walk
526
XLKSfXG
at times — astasia abasia — whereas in an hour or two this power may entirely return. Temporary Iocs of speech and abnormalities of sight are often met with. In an hysterical attack the patient may laugh or cry. scream or be dumb j she may fall and lie apparently un- conscious or may struggle violently. A more aggra- vated form of attack occurs in what is known as hystero-cfiltpsy. A hysterical attack often resembles an epileptic seizure, btit may iguished from it
by the fac: that the patient is only partly unconscic the reflexes are active, and the cry and grinding of the teeth peculiar to epileptics are absent. Moreover, the patient seems to be careful not to hurt herself, although she may fall and throw herself into the most grotesque contortions. In all forms the urine is increased in quantity ; it is generally pale and of a low sjK-cific gravity. Such patients should be watched carefully, but without allowing them to become con- scious of the fact, in order to learn what symptoms are real and what are feigned. So far as the nurse is con- cerned, the methods of treatment in neurasthenia and hysteria arc very much alike. She needs to be sym- pathetic, but very firm without being in the least un- kind. In the milder forms a little well managed ap- parent neglect is sometimes whokrsomc, as such pa- tients love to be fussed with. Rest in bed, careful nourishment and later massage arc usually indicated. The influence of a capable nurse in strengthening the general morale of the patient is, however, always im- portant.
F.(<ile[<sy. — A brief description of an epileptic at- tack is to be found elsewhere Cp.304). Hetween the attacks epileptics are often bright, good-tempered and
tNSOAfMA
5I7
able to carry on their cvery-day work. Some, how- ever, especially after the cliseUG has lasted a long time and the attacks have been frequent, show a greater or less degree of mental enfecblcmcnt and arc often very troublesome patients.
Insomnia is often a very troublesome symptom with which the nurse has to contend, and is met with under many conditions. It is often the result of some nvr votis disease, but when it persists it also aggravates the condition which lias caused it. In order to cure insomnia, when possible, the cause must be removed. Besides the removal of all sources of worry, indiscre- tions in diet must first be corrected, tea, coffee, and any articles of food which might produce indigestion or over-stimulation being restricted or forbidden alto- gether.
Gentle massage, a tepid bath or sponging the body with tepid water at bed-time or cold or warm packs are often helpful. The bed must be made comfortable. There should be sufficient but not too much covering ; the feet should be kept warm and the head cool. Of- ten a glass of warm milk, beef tea or .cocoa, at bed- time, and the reading in a somewhat monotonous tone of some unexciting literature will send the patient into a comfortable sleep. Hypnotics or stimulants should never be given without express orders from the phy- sician.
Certain forms of insanity arc necessarily met with in the wards of a general hospital. In the first place pa- tients may develop a form of insanity daring the course of an acute disease or during convalescence. Again, insane patients arc sometime* admitted tem- porarily for surgical reasons. Post-febrile insanity is
NURSING
not infrequently met with after severe cases of fever — especially typhoid fever or influenza — after child-birth and after surgical operations. In a general hospital a nurse should always remember the strain that is put upon new patients who have left their homes and have come to submit, perliaps, to some serious operation. Nurses who have submitted to operations themselves have told me how much they had learned thereby. V who are accustomed to hospitals are too apt to forget that almost every patient must undergo mental suffer- ing to some extent and to those who have a highly- nervous organization this amounts to an agony. A little thought, kindness and consideration on the part of the nurse will often effect far more than she ex- pects.
Some of the advantages of a course of study in an asylum wen- mentioned at the beginning of this chap- ter. In addition the nurse will leant many line d< mils of nursing, which arc not of such vital importance, but with certain modifications can often be utilized in tin- case of a sane patient. Thus she will get a good understanding of the line of moral treatment to be pursued, the uses and indications for seclusion, re- straint and freedom; of the peculiarities of different dispositions, the importance of congeniality and com- patibility : the uses of employment, amusement and exercise ; the special precautions employed for the safe- r. of the patient and nur* . and the special forms of treatment employed. Furthermore, she will have an added opportunity for putting into practice various procedures which sli« has already learned — the giving of baths and electricity, and the various hydrothera- peuttc procedures. In an insane hospital she can also
THE REST CURE
529
add much to her knowledge about food and suitable dietaries; she will be taught how insensible or frac- tious patients can be nourished — by forced feeding — and how unpromising patients by dint of kindness and tact can be made to assist the physician and nurse in improving their condition.
Good nursing in mental and nervous cases is far more exhausting and requires much more intelligence and broader capabilities than those necessary for one who limits herself to taking care of fever or surgical patients. In CMOS <if nervous disease the nurse is required to give of her best, the mental qualities stand- ing for much more than physical labor. If a woman after having had a good general training is successful in taking care of nervous patients we need never fca. to entrust her with any case of sickness.
The Rest Cure. — We will only say a few words on a method of treatment so frequ Bribed in cases
of hysteria and neurasthenia, which has obtained the name of "the rest cure." and has been so strongly rec- ommended and so much written about by Weir Mitch- ell, Playfair. and others. The patients to whose cases it is particularly applicable are those suffering from nervous exhaustion, such ;is is seen in ncr\ 1 hysterical women. Where the prostration is severe, in order to procure much relief the patient must in most cases be removed from her home and placed in an in- stitution where she may have the advantages of this "rest-cure treatment." To become expert in dealing with these patients it would lie advisable for a nurse, if she intends to devote herself especially to the care
Of such cases, to spend some months in a hospital 34
53°
SUKSIXG
where the treatment of rocs diseases is made a special- ty.
The first step in the enre is to ensure the complete isolation of the patient No one should see her but the nurse, the physician, and the masseuse. Absolute rest in bed. massage, electricity, and systematic over- feeding are desirable. Very little if any reading, and no sewing or writing of letters, should be allowed. Usually the patient is kept in bed for from four to ten weeks. The massage is an important feature, and should be given at first very gently for a few minutes *. a time, and gradually increased. The food should be abundant, easily digestible, and given at regular in- tervals. For extreme nervousness or sleeplessness the hot foot-bath, the warm full bath and hot or cold packs are used.
The nurse, while very firm, should be especially bright, cheerful, and good-tempered, but she must observe a happy mean and be careful not to be over- sympathetic with her patient. When the nervous sys- tem has become rested and strengthened, it is advisable to allow the patient to return gradually to her former occupations and habits of life.
Massage, a word coming through the French from the Greek verb meaning "to knead," also includes rub- bing and light pounding combined with stimulation of !hc skin by friction and slapping. These various pro- cedures now constitute a very valuable resource of •n therapeutics. To become an expert not only n itiiral gifts — above all the possession of a suitable hand, a good physique and a special temperament — but a scientific training and long practice are also necessary. Naturally, then, we cannot expect that ev-
MASSAGE
53 >
cry graduate should leave a general training-school for nursing as an expert masseuse. Nevertheless it is not only desirable but absolutely necessary that the nurse should have a good general knowledge of the principles of massage, its physical and physiological effects and its general application, because such knowl- edge will enable her to do much for the relief and comfort of almost any kind of patient Take, for in- stance, the simple rubbing of the back. How much better it can be done if the nurse understands the proper movements necessary in grasping and manipu- lating the muscles to increase circulation or to produce a sedative effect. As a rule the patient will quickly distinguish between an intelligent massage and mere haphazard rubbing and will be grateful to the nurse in proportion to the amount of comfort received from the procedure. General massage for its tonic effect can very well be given by the nurse to convalescents from pneumonia, typhoid fever and other acute con- ditions. In the hands of an expert masseur or mas- seuse this treatment is now ordered for various condi- tions— medical and surgical— especially in conjunction with the rest am- and for th« benefit of joints thick- ened and stiffened as the result of inflammatory de- posits.
The teaching of the subject is only possible after the student has acquired I good knowledge of human anatomy and physiology. She must know the location, function and action of the various bones, joint*, mus- cles and internal organs, as well as their sources of nu- trition.
Scientific massage is meant to take the place of active voluntary exercise, under circumstances that
S3*
.\UftS/.\G
have rendered the latter impossible. It gives tone to the muscles, aids the circulation of the blood and in- creases the action of the skin, thus promoting the sorption of nourishment and the removal of waste ma- terial from the system. It can be made to exercise either a stimulating or a sedative effect upon the nerves, the latter being especially desirable in cases of insomnia. It is also prescribed for the reduction i if swelling from sprains and other causes, for the grad- ual separation of adhesions and to promote peristalsis of the bowels in cases of chronic constipation.
It can be readily understood what an important part the hand plays in massage. The touch must be gentle but firm. The hand must be normally warm, dry, and impart a certain sensation of delicacy and elasticity. The woman who has a cold clammy hand can never give a satisfactory massage.
For the procedure itself a few fundamental rules always hold good : A loose corset waist mull be nrom instead of a corset, the dress should be white and fresh and the hands free from rings and the scent of toilet soap. The bed or couch should be placed out of the way of drafts and the mattress should be firm but not too hard. The patient is wrapped in a gown and placed between two blankets. Only the part being treated should be exposed and care should be taken not to al- low the patient to be chilled. For giving a general massage the nurse stands on the right side of the bed and begins with the lower extremities. The duration of the treatment never exceeds an hour and at first twenty minutes to half an hour is quite long enough. The manipulations are made slowly and evenly, the whole hand being employed, particularly the palm
ELECTKICITY
5.3.3
and the thick part of the thumb. For deep massage all the work should be from the extremities towards the trunk, from the insertion to the origin of the muscles and in the direction of the reluming current* of the circulation. After the treatment the patient should rest for at least an hour. The time at which the mas- sage should be given varies according to circumstances and the object for which it is prescribed. Where a soothing effect is desired the treatment should be gentle and given at night, the patient being allowed to go to sleep immediately afterwards. For a stimulating ef- fect a brisk massage may be given in the morning, two hours before or after a meal.
During a treatment the nurse should not talk more than is necessary. The lower extremities are takes first, then the thighs, the upper extremities, che^ domen and finally the back. First comes friction of the skin, then the gradual kneading and stroking of the muscles and lastly percussion and vibration. When ordered, passive motions are added, the work on one part being finished before another pait if taken in hand Only from practical demonstrations of the actual man- ipulations as applied to an actual patient can the stu- dent gain even an approximate idea of the proper methods.
Electricity. — Three forms of electricity arc employed in medicine — the galvanic and faradic currents and static electricity. The first two arc often used for diag- nostic purposes, inasmuch as a good deal of information can be gained from finding out whether given nerves or muscles react to cither one or both of the currents. Moreover, the nature of the reaction, when present. i> important. Under the direction of an expert tin mine
53*
yvxstxu
•3= r-arHy !earr a fioaa aicct rise various forms of ajcara=j erricjrrf r: ztts ±e srrpfcr kinds of ebsc-
— »; i_-ic Bp tut D9np-
•miierairn by the
VOCABULARV.
MEDICAL.
C\
Aome, ak'me. Crisis or height of a disease.
Acute, .'i-kiii'. An acute disease, one in which the onset, prog- ress, and termination are rapid. Applied to pain, acute means severe, sharp.
Affu'sion. A pouring upon ; t. g. affusions of water are used to reduce temperature.
Algid, al'jid. Cold, chilly.
Aliment'ary. fattlnlag to nutrition.
Anaemia, an-e'me-ah. Deficiency in the number of red cor- puscles or of the coloring matter of the blood.
Analgesia, an-al-je'se-ah. Insensibility to pain.
Anasar'oa. General dropsy.
An'gina Pec'toria. Pain and oppression about the heart.
Anodyne, an'ft-dm. An agent which relieves pain.
Anorexia, an-or-cks'e-ah. Loss or diminution of appetite.
Antipyretic, (subi.) An agent which reduces fever; \adj.) fever reducing
Aphasia, ah fa'reah. Partial or complete loss of the power of speech.
Aphonia, ah-fon'e-ah. Loss of voice.
Ap'oplexy A sudden paralysis (genctally from rupture of a cerebral vessel).
Apyrezia, .il> pi -n-ks'e-ah. A state of freedom from fever.
Ascites, a-si'lto. An abnormal collection of fluid in the aodommal cavity.
VOCABULARY.
Asphyx'ia. Suspension of animation from lack of oxygen in
the blood. Aspira'tion. A method of withdrawing fluids by means of
the aspirator. Asthenia, ah-sthe'ne-ah. Loss of strength. Weakness. Ataxia, alax'e-ali. Incoordination of muscular action. Atrophy, at'ro-fc. Wasting of a part from lack of nutrition. ' Aura, o'rali, A peculiar sensation, such as usually precedes an
epileptic fit. Auscultation, os-cul-ta'shun. The act of listening to sounds
produced in organs of the body, usually tile heart and lung Benign'. Mild, not malignant. Borborygmus, bor-bo-ryg'inus. Rumbling in tbe intestines. Cachexia, kak-ex'e-ah. A depraved condition of nutrition. Cada'ver. The dead body. Centigrade Thermometer. A thermometer the scale of
which is divided into too parts or degrees, o° representing the
freezing-point and too'' the boiling-point of water. Chore's. A disease characterized by involuntary muscular
twitching* ; St. Vitus' dance. Chronic, kron'ik, I.ong continued, often opposed to tuut*. _ Clinic, klin'ik. Bedside instruction. Collapse'. Complete prostration of the vital powers. Co'ma. A state of profound stupor. Oo'ma-vigil. A condition of unconsciousness and delinum
in which the patient lies with open eye*. Contagion. The communication of a specific disease by
contact. Coordination. Harmonious action ; e.g. of muscles. Contraindication. Indication against. Corpuscle, kor-puvl. A minute body ; a cell. Crisis, kri'sis. The turning-point in a disease. Cyano'eis. Bluish color of the skin, due to imperfect oxi- dation of the blood. Decubitus, dc-ku'bi-tus. The recumbent position. A form
of bed-sore. Defervescence, dc-fcr-ves'en*. Decrease of fever.
VOCABULARY.
537
Deglutition, deg-lu-tish'un. The act of wallowing. Dejection, de-jck'shun. A discharge of faecal manor. Delirium, de-lir'e-utn. A wandering of the mind Dementia, dc-men'shc-ah, Form of insanity witli ioiaof the
reasoning powers. Depletion. The withdrawal of fluid from some part of the
body. Desquamation, deskwa-ma'shun. Peeling off; t.g. of the 0 outer skin. Diagnosis. The recognition of disease from its signs and
■ymptoms. Diathesis, di-ath'e-sis. A predisposition to disease. Dicrotic, dlkrot'ik. A term applied to a pulse which gives
the sensation of a double beat for each contraction of the
heart. Dyspnoea, disp-ne'ah. Dltt ult or labored breathing. Em'bolism. The obstruction of a blood-vessel by an embolus
or plug. Empyema, em-pl'e-mah. A collection of pus in the pleural
cavity. Epistaxis, ep-i-stak'sis. Hemorrhage from the nose. Eructation, c-rxik-ia'shun. The bringing up of gas from the
stomach. Exacerbation, eg-ias-er-ba'shun. Increased severity of symp- toms. Excreta, cks-krc'l.'ih. Natural discharges of the body. Expectant, eki-pek'tant. Amfttng; e. g. the expectant mode
of treatment by non-intcrfcrcnc*. Expiration, cks-pl-r.i'shun. The act of breathing out. Faeces, te'ses. The discharges from the bowels. Febrile, fe'brll. Pertaining to fever. Fissure, fish'ur. A crack. , Flat'ulence. The presence of gas in the alimentary canal. Fluctuation, fluk-tn-.Vshun. The undulation of contained
fluid upon pressure. Formica tdon. Sensation as of ants creeping over the body.
538
VOCABULARY.
Gastritis, gas-trf'us. Irulammatjoa of the srnmacb,
Gavage (Ft.) Forced feeding.
Globus Hyatar'icua. Seasaaoa (tn hysteria) as of a ball in the throat.
Hasmatsmcsfc, be-mat-eaj'e-sJa. The vomiting of blood.
Hsemoglo'bin. The coloring matter of the red corpuscles.
Hsnnoptysia, hem-opti-sis. The spicing of blood.
Haemorrhage, hetn'or-aj. Flow of blood from the vessels.
Hemostatic, hem-o-stat'ik. Arresting haemorrhage . (suit.) an agent to stop hxmorrhage.
Hectic, hek'tik. Pertaining to wasting or phthisis.
Hemiplegia, hem-i-pleg-e-ah. Paralysis of one side of the body.
Hepatization. Change into a liver-tike substance.
Heredity, her-ed'i-tc, The transmission of traits of ancestors to their offspring.
Hiccough, hic'kup. The spasmodic contraction of the dia- phragm with sudden closure of the glottis.
Hydrop'athy. Treatment of disease by the use of m-atcr.
Hydrothorax. A condition in which there is a water)- fluid in the pleural cavity.
Hygiene, hl'je-en. The science of health.
Hyperemia, hl-pcr-e'mc-ah. Excess of blood in the vessels of a part.
Hyperpyrexia, hl-per-plreks'e ah. An excessively high tem- perature of the body.
Hyper'trophy. An abnormal increase in the size of a part or ..i, .in
Hypnotic, liip-not'ik. Sleep-producing ; (tuts.) an agent which produces sleep.
Hypoder'mio. Under the skin — applied to the injection of medicines under the skin.
Hyperaeatheaia, hl-per •cs-thf ?e-ah. Excessive sensibility.
Icterus, ik'ter-us. Jaundice.
Idiosyncrasy, idi-o-sin'kra-se. Individual peculiarity.
Inanition. Exhaustion from starvation.
VOCABULARY.
539
Incottrdination, in-cd-or-din-a'shun. The state of inability to produce coordinated muscular movements.
Incubation, inku-ba-»hun. The period which elapses between the introduction of the contagium and the development of the symptoms.
Inges'ta. Substance* introduced into the body by the mouth.
Infection. The communication of the germs of disease.
Inoculation. The introduction of a specific virus into the system.
Insolation, in-so la'shun. Sunstroke.
Inunction. The act of rubbing in an ointment.
Lactom'eter. An instrument for measuring the specific grav- ity of milk
Lac'toecope. An instrument for testing the quality of milk.
Laryngismus Strid'ulus. Spasmodic contraction of the glottis; false croup.
La 'tent. Concealed, not manifest.
Lavage (Fr.) Irrigation of the stomach.
Le'sion. A morbid change in the function or structure of a tissue from injury or disease.
Leth'argy. A condition of drowsiness.
Lysis, li'sis. Gradual decline, mote especially of a febrile disease.
Macera'tion. Steeping in fluid to produce softening.
Marasmus, mar-ar'mus. A wasting or emaciation.
Metastasis, mct-as'ta-sis. Change in the scat of the disease.
Me'grim. Neuralgia or headache of one side of the head.
Narcofio. Producing narcosis; (subs.) an agent which pro- duces a condition of lethargy or sleep.
Nephritis, nef-rl'tis. Inflammation of the kidneys.
Neurasthenia, nfl-ras-thf ne-ah. Exhaustion of nerve-force.
Neurosis, nu-rcVsis. A nervous affection of a functional nature
Non Com'pos Men'tds. Of unsound mind.
Nostalgia, nos-tal'je-ah. Homesickness.
(Edema, e de'mah. Accumulation of serum in the cellular tissue.
;«3
V0CABU1.AK Y
Ophthalmia, ocT-thal'tnc-ah. Inflammation of the conjunc- tivae.
Orthopse'dic. Pertaining to the correction of deformity.
Orthoptics 'a. Difficulty in breathing, relieved only by the upright position.
Omno'si*. The diffusion of fluid-; through membranes.
Psediatrics, pcd-c-at'riks. The treatment of the diseases of children
Palliative, pal'iativ. Mitigating, relieving.
Paracentesis, par-a-sen-tc'sis. The operation of puncturing a cavity of the body (in order to draw off fluid).
Paraple'gia. Paralysis of the lower half of the body.
Paresis, par'evis. Slight paralysis. Partial loss of muscular power.
Paroti'tlB. An inflammation of the parotid gland. The mumps.
Pathogen'ic. Causing disease.
Percus'mon. Light tapping or striking on any part of the body for diagnostic purposes.
Peristal'sis. Undulating movements of the intestines.
PortuB'uis. Whooping cough.
Photopho'bia. Abnormal sensitiveness to light.
Pro'dromea. Precursory symptoms.
ProphylaxiK, pro-fil-aks'ls. Prevention of disease.
Ptomaines, to'ma-lns. Alkaloids formed during the decompo- sition of organic matter.
Quotidian, kwotid'i-an. Occurring every day ; t.g. quotidian fever in which the paroxysm occurs every day.
Radical. A form of treatment meant to destroy a disease.
Reec'tion. Recuperation or return of power after depression
Recur'rent. Returning at intervals.
Ro'flex. A term applied to an involuntary action produced I an indirect nerve-stimulus.
Refjrurgita'tion. "P"16 flowing back or the rejection of the contents of a hollow organ.
Relapse'. Recurrence of the disease before complete conva- lescence.
VOCABVLARV.
541
Remit'tent. Resolu'tion.
Alternately abating and returning. The gradual return of the U»ues to their normal condition after inflammatory condn
Retching. Attempts at vomiting.
Rhythm, rithm. A measured movement.
Rigor, n'gor. A chill. Rigidity.
Rigor mortis. The muscular rigidity which occurs shortly after death.
Satura'tion. A term used to denote that a fluid contain* a.« much of a solid substance as it can dissolve.
Sequela, se-kwel'ah. Abnormal condition following the de- cline of a disease.
Singul'tus. Hiccough.
Sopor, so'por. A drowsy condition.
Sordea, sor'-dei The brownish deposit that tends to accumu- late about the teeth in disease.
Sporad'ic. Scattered, or occurring in isolated cases or groups.
Steno'sis. Constriction or narrowing.
Stercoraoeoua, stcr-kd-r.i'she-us. A term applied to vomited matter containing farces.
Ster'torous. Breathing with a snoring sound.
8tomatitia, sto mat-i'tis. Inllammation of the month
Strabis'mus. Squint. Condition of the eyes in which the visual axes do not meet at the desired objective point.
Striduloufl, strid'u-lu. Making a harsh or strident sound.
Subacute'. Midway between acute and chronic.
Subeul'tus Ten'dlnum. Muscular tremor or twitching.
Sudorific. Sweat-producing ; Uubs.) an agent which induces sweating.
Syn'theeia. Formation of a compound by the uniting of its
Syn'oope. Fainting or swooning. [elements.]
Tabes, ta'bto. lYogrestivc emaciation.
Tabaa doraalia. A disease of the nervous system, sometimes called locomotor ataxia.
T*»nee'mUH. The painful desire, coupled with straining, to empty the bowels or bladder.
54*
VOCABULARY.
Tberapea'tioB. The medical science relating to the applica- tion of remedies. Tbennom'etar. Instrument for measuring intensity of heal. Thrombo'sie. The fonnatioa of a blood-clot in a vessel. Tor'mina. Griping para in the bowels.
Toz'lC. Foisooous.
Traumatic, traw'mat'ic. Pertaining to a wound.
Tus'ais. A cough.
Tympanitea, um-pan-t'tex. The distention of the abdomen
» iili gas. UrtJea'ria. Nettle-rash. Vaccina'tioo. Inoculation with a virus obtained from cows to
protect against small-pox. Variola. va-rt'o-lah. Small-pox. Vas'cular. Pertaining to vessels. Ver'tigo. Diuincss. Vee'icl©. A small blister. Vicarious, vl-ka're-us. The term applied to the assumption
of the function of one organ by another. Vol'atdle. Readily evaporating. VuVooua or Viscid. Glutinous. Ropy.
SURGICAL.
Abra'oion. Excoriation of the skin or mucous membrane.
Acupressure, sk'u-prcss-ur. The compression of blood-ves- sels by means of needles.
Ac'upuno'ture. Puncture of tissues with needles for the relief of pain.
Adono'tna. A glandular tumor.
Adhe'aion. The growing together of two surfaces or parts.
Amputa'tion. A removal of a part of the body.
Anserithe'aoa. A condition in which sensation is lost.
Anastomo'sis. The junction of vessels.
Anffio'ma. A tumor formed of Mood -vessels.
Ankylosis. -Stiffness of joint due to adhesions between iu surfaces.
VOCABULARY.
543
Antisep'tio. Preventing the growth of organisms which pro- duce putrefaction
Apposi'tion. In contact
Arthritis, ar-thri'tis. Inflammation of a joint.
Asepsis, a-sep'sis. The absence of scpti^ nutter
Afl'plrator. Instrument for Withdrawing fluids from W
Atheromatous Degeneration, ath-c-ro'ma-tus. Katty de- generation of arterial walls, with deposition of lime talis, rendering the vessels brittle.
Bifurcate, bi-fer'kat. To divide into two branches.
Bistoury, bis'too-r*. A n.uruw-liladed knife used in surgery.
Bougie, boo-zhe'. Cylindrical iostriKMOl i"i dilating canals.
Cal'loua. Hard.
Callus. New bony deposit about a fracture.
Cann'ula. A small tube.
Carcinoma, kar-se-no'ma. Cancer. A malignant form of tumor.
Ca'ries. A local death of bone.
Caus'tic. Burning; (mts.) a substance which destroys living tissue.
Cellulitis, sel-ii-li'iis. Inflammation of the cellular tissue.
Cicatrix, si-ka'triks. The scar which remains after the healing of a wound.
Cicatrization, sik-a-tri-jA'shun. The process of healing.
Circumduction. Circular movement of a hmb.
Clon'ic. Applied to spasms with alternate contractions and re- laxations.
Coagula'tion. A clotting.
Coapta'tion. The adjustment of edges of wounds or frac- tured hones.
Oomminu'tion. Breaking into pieces.
Golot'omy. Incision into the colon.
Oontu'sion. A bruise.
Coun'ter-sxten'sion. Opposing traction upon a limb in ex- tension.
Crepitus. The grating of the ends of fractured bones.
Cystotomy, sis-tot'o-mc. A cutting into the bladder.
544
VOCABULARY.
Demarca'tkm (Line of). The line dividing dead from living
tiwue. Diaartdcula'tion. Amputation of a limb at a joint Dom'lll. Pertaining to the bock.
Emphyse'ma. Distension of tissues with air or other gases. Empyema, cm-pi-e'mah. A condition in which there i* pus in
the pleural cavity. Enucleation, e-nu-klce-.'i'shun. The peeling out of a tumor
from its sack. (Of the eye.) The excision of the eyeball. Epithelioma, ep-i-the-le-6'mah. A cancerous growth of the
skin or mucous membrane. Es'char. The dry crust of dead tissue.
Efl'maroh'e Bandage, Elastic rubber bandage used to pre- vent or control haemorrhage. Ever'sion. The folding outward. Excia'ion. Act of cutting out or away. Excoria'tion. Abrasion of the skin. Excrescence, cks-kTcs'cns. An abnormal outgrowth. Exten'sion. Traction upon a fractured or dislocated limb.
The opposite of flcxi'm Extirpa'tion. The removal of a part. Extravasa'tion. Effusion of fluid into the tissues. Exuda'tdon. The oozing out of fluids. Fenes'trum. An opening. Fistula, fis'tu-Uh. An abnormal opening between two parts
of the body. Fixation. A making firm or rigid. Flexion, flek-shun. The process of bending. Fluctuation. Wave-Ukc motion. Graft. Transplanted living tissue. Granuln/tionn. A reticulated framework of tissue containing
i in1. II .
Hematoma, hcnvat-6'mah. A tumor containing blood. Her'nia. Protrusion from its normal cavity
normal or aruficial openings in the surrounding
structures.
VOCABVI.AK y.
545
Immobilization. The act of facing a part in such a manner at to render it immovable.
Impac'tion. The condition of being wedged together.
Incis'ion. A outing into. A . at
Indura'tioc. Hardening of a pan
Inflamma'tdon. The response of living tissue to injury.
Intuba'taon. Tin- rUMtklfl of a tube into the larynx.
Inver'sion. The turning of an organ inside out or upside down.
Liv'id. Having a dusky bluish color i due to congestion).
Necrosis, ne-kro'sis. Death of tiuue.
Ne'oplasm. Anewgrowih
Occlusion, ok-lu'*hun. A scaling or blocking up.
Ossiflca'tion. formation of bone.
Oatalgia, os-tal'jc-ah. Pain in bone.
Osteomyeli'tia. Inflammation of the bone, (to.) of the mar- row of the bone.
Osteotomy, osteot'omy. A cutting operation on bone.
Perforation. An opening or penetration.
Phlebitis, flc-hi'tis. Inflammation of a i
Plas'tic Operations. The engrafting of tissue from one part to another.
Prona'tion. Position of the arm when the palm of the hand is turned downwards.
Pyeemia, pi-e'mc-ah. Septicemia with ab»ce»-formatioTU.
Reseo'tion. Excision of a portion of DOBS,
Reeolu'tion. The gradual disappearance of inflammatory products without the formation of pus.
Retrac'tion. Shortening Drawing backward.
Saprte'mia. Septic intoxication. Blood-poisoning.
Saroo'ma. A malignant tumor having the structural charac- teristics of connective tissue.
Scarification, skar-if-ik-a'shun. The operation of making numerous small niparfii 001 in a part.
Sep'tic, Relating to putrefaction.
Sequestrum, se-kwes'trum. A fragment of necrosed bone.
54«
VOCABULARY.
Slough, sluf. A portion of dead tissue which comes away
.ii'ii-r an ulcerative proa Strangula'tion. Constriction. Choking. Stricture, smk'tiir. A contraction of a duct or tube. Styptic, stip'tik. Astringent; (subs.) an agent which stops
hemorrhage. Subcuta'neoua. Under the skin. Sxitru'nion. Slight diffused congestion. Supination, su-pm-ii'shun. Position of the arm when the
of ihr hand i'i turned upwards. Su'ture. Junction of cranial bones. In surgery, a stitch. Synovitis, si Inflammation of a s> noviaJ membrane.
Tax'is. The manual rcdoi fan of a hernia.
Ten'sion. Tight new. A condition of being drawn tight.
Tor'sion. A twi
Tourniquet, toor'nik-et. An instrument to compress arteries.
Toxeemia, tolwtfacan Poisoned state of the blood.
Traction. A drawing or pulling.
Transfusion. The injection of blood from the vessels of one
person into those of another. Transuda'tion. An oozing through. Traumatic, traw-mat'ik. Pertaining to a wound. Trismus. Lockjaw. Trocar. An instrument consisting of a stilette contained In a
metal tube, used for evacuating fluids from cavities. Tumefaction. Swelling of a part. Turgeeoonoo, ter-ges'ens. Swelling or enlargement of an
organ. Turgid, ter-jid. Swollen. TJl'cer. An open sore. Varicose, var'ik-os. A term applied to dilated and tortuous
veins. Veneeec'tion. The operation of opening a vein. Vee'icle. A small Hitter or sac
VOCABULARY.
547
GYNECOLOGY.
Adnexa. Appendages — i. t. the tall.»pian tubes and ovaries Amenorrnce'a. Irrcgul.inty or supp<cssion of menstruation. Anteflexion, an-lc-flek'shun. A bending forward. Antever'sion. A turning or leaning forward. Catamenia, kat-a-me'ne-ah. The menses. Climacteric. A critical period in life. Generally used to
signify the time of life at which the catamenia cease. Cyst, sist. A sac containing fluid. Cystocele, sist'6-scl. Vesical hernia. Defeca'tion. Evacuation of the bowels. Douche, doosh. A stream of water directed forcibly against *
part. Dysmenorrha>a, dis-men* re'ah. Painful rrenstruation. Endometri'tis. Inflammation of the lining n.-mbmnc oi the
uterus. Gen'u-pectoral. I'crtaining to the knee - ' hest. HsematosaTpinx. Distension of the K....-pi*n tube with
blood. Leucorrhcea, lilkor-e'ah. Wlutis.li . narge from the vagina. Menorrhagia, men-or-a'je-ah. Exct -sive menstrual flow. Menses, men'sti. The monthly flow tiom the utcrus- Men'opause. The end of the menstrual life. Metri'tifl. Inflammation of the utmi*. Patulous, pat'ulus. Expanded. 0|ien. Ped'icle. The stem or narrow portion of a tumor by which it
is attached to a part. Pes'sary. Instrument placed in the va„ina tj support the
uterus. Prolap'sus Uteri. Protrusion of the uterus as far as or
beyond the vulva. Retroflexion. A bending backward* Retroversion. A turning or leaning i, < vvds. Sal'pinx. The Fallopian tube. Subinvolution. Insufficient lavohtdoa Superinvolu'tion. Excessive involution
54»
VOCARULAR Y.
Tu'bal. Pertaining to the tube or oviduct.
U'tertifl. The womb.
Vagrina, va-ji'nah. The canal from the vulva to the uterus.
Vagiui'tdfl. Inflammation of the vagina.
Vul'va. The external female genitals.
OBSTETRICS.
Abor'tion. The expulsion of the embryo at any time during
the first three months of pregnancy. Accoucheur, ah-koo-shur'. An obstetrician. Am'nion. The inner embryonic membrane. An'te-Part'um. Before delivery. Ballottement, bal-lot'mong. A method of examination for
pregnancy. OauL Fcetal membranes covering the head. The omentum. Chorion, k&-re-on. Outer membrane enveloping the foetu$. Colostrum, ko-los'trurn. The first milk secreted after labor. Oongen'ital. Existing from birth.
Oraniot'omy. The operation of breaking ap the ftetal skulL Decidua, de-sid'u-ah. Membranous envelope of ovum in the
uterus. Deliv'ery. Childbirth.
Fimbriae, fim'bre-e. Threads or filament* ; a .ringe. Fce'tUS. The unborn child. Fontanelle (Fr.) Membranous space at the junction of the
cranial bones in an infant where ossification is incomplete. Genita'lia. The organs of generate". Gestation, jet-ta'tion. Another term for pregnancy. In'oubator. An apparatus kept at a uniform temperature of
86° to 88°. devised for the rearing of premature children. Intra-u'terino. Within the uterus. Involution. The process by which the uterus returns to its
normal condition after pregnancy. at
VOCABULARY.
54 ')
Laoera'tion. A tearing.
Lacta'tion. A tcmi used to mean the period during which the
child nurses. Lanugo, lan-0'go. Downy hair on the new-born. Liquor Amnii, li'kwor am'ne-l. Fluid surrounding thefectus. Lochia, lo'ke-ah. Vaginal discharge after labor. Mam'mary. Pertaining to the breasts. Masti'taa. Inflammation of the breast. Meconium, me'kd-ne-um. First fecal discharge of the new-
lllll II
Multip'ara. A woman who has borne several children.
Nae'vus. Birth-mark (generally due to the dilatation of blood- vessels). A mole.
Omen'tum. A fold of peritoneum covering the viscera.
Palpa'tion. Exploration with the hand (for diagnostic pur- poses).
Parturi'tion. The act of giving birth to young.
Phlegma'sia Do'lene. CEdcma of the leg from venous ob- trui lion ; milk-leg.
Placen'ta Prse'via. Presentation of the placenta before the fectus.
Preeenta'tion. A term used to denote which part of the fetus comes first to birth.
Primip'ara. A woman pregnant with, or who ha* borne only, her first child.
Puer'peral. Pertaining to child-bearing.
Quick'ening. first perceptible movements of the fetus in utero.
Secundine. sek'un-din. The after-birth.
Subinvolu'tion. Imperfect involution.
Symphysiotomy, sim-fii-e-ot'o-me. Section through the symphysis pubis.
Ver'nix Caaeo'aa. The cheesy material which covers the fetus.
Ver'sion. Turning of the MMtt m utero.
Vi'able. Capable of living.
55<>
VOCAItVlAKY.
URINARY ANALYSIS.
Acet'ic acid. C,H,Or Acid of vinegar. Albuminu'ria. The presence of albumin in the urine. Amorphous, a-morf'us. Formless. Non-crystalliicd- Am'yloid. Starch-like.
Anal'yais. The resolution of a body into its elements. Anuria, an-il'rc-ah. Absence or deficiency in amount of
urine. BU'iary. Pertaining to the bile. Blood-caste. Abnormal microscopic bodies in urine, being
moulds of urinary tubules made up of blood-cells. Cal'culus. A stone-like concretion found in ihe body. Cal'culus, Re'nal. Stone found in the kidney. Cal'culus, Ves'ical. Stone found in the bladder. Ohyluria, ki-lu're-ah. The passage of milk-like urine Cysti'tiB. Inflammation of the bladder. Cystot'orny. Incision into the bladder. Diaphoret'ic. An agent which produces perspiration. Diuresis, dt-fl re'siv Excessive secretion of urine. Diuret'io. An agent which Increases the flow of urine. Drop'sy. The effusion of fluid into tissue* or cavities of the
body. Dysuria, dis-u're-ah. Difficult or painful micturition. Enuresis, cn-u-re'sis. Incontinence of urine. Piltra'tion. The process of straining or filtering. Glomer'ulus. A knot or small tuft of vessels (particularly in
the kidney). Glycosuria, gllkosu'rc-ah. The passage of sugar in the
urine. Grav'el. Sand like deposit in the urine. Haematuria, hem at-u're -ah. The passage of blood in the
urine. Hlppu'rlc Acid. An acid normally found in small quantities
in human urine, and in larger quantities In the urine of her-
Kvotous animals. iDOOO'tinenoe. Involuntary evacuation of the unne o. faxes.
Vocabulary.
55 1
Lith'ic. Pertaining to stone.
Lithot'omy. Cutting into the bladder for stone.
Lithot'rity. Cnuhing a atone in the bladder.
Lifmus. Blue pigment turned red by acid ; or red pigment turned blue by alkalies.
Mea'tue. A passage or opening.
Meatus Urinariua. The opening into the urethra.
Metamor'phosis. Transformation ; structural change.
Micturi'tion. The act of voiding urine.
Nephreo'tomy. The operation of cutting out the kidney.
Nephritis, nef-rt'tis. Inflammation of the kidneys.
Nephrot'omy. The operation of cutting into the kidney.
Opacity. Non-transparency.
Pig'ment. Organic coloring matter.
Pipette, pip-ct'. A small glass tube for taking up fluids.
Polyuria, pol-e-u're-ah. Excessive secretion of urine.
Precip'itate. Anything changing from a soluble to an insol- uble form in a solution.
Pyelitis, pi-el-i'tis. Inflammation with formation of pu' in the pelvis of the kidney.
Pyuria, pl-o're-ah. The presence of pus In the unne.
Quantitative. Pertaining to quantity.
Rea'gent. Anything producing a reaction.
Reten'tion. Holding back. The act of retaining urine i» the bladder.
Saccharometer, sak-arom'et-er. An instrument by means of which the amount of sugar in a solution can be estimated.
8ed'iment. Matter which settles at the bottom of a liquid.
Specific gravity. Weight of a substance compared with that of distilled water.
Strangury, stran'gu-re. Painful urination in drops.
Stric'ture. A contraction existing in a duct or tube.
Suppression, Concealment . failure of the kidneys to secrete urine.
Transuda'tion. Oozing of a fluid through the pores of the skin.
Urse'mia. Toxic condition of the blood, due to the nun excre- tion of effete substances (formerly suppo-.e<l to be
VOCABULARY.
Urates. Salt* of ark acid.
Urea. u-re'ah. Chief solid constituent of urine; a nitrogenous
product of tissuc-detumpujition. Ur'eter. The tube which carries the urine from the kidnc> to
the bladder. U'ric ac'id. An acid normally found in small amount In
human urine. Urinom'eter. Instrument for measuring the specific gravity
of urine.
BACTERIOLOGY.
Aero'bic. Living only In the presence of oxygen or air. Amce'ba. A colorless protoplasmic animal micro-organism. Anaero'bic. A term used of microorganisms which are pro- duced or which live in the absence of oxygen. Aut'oolave. Instrument for sterilizing by means of steam
heat under pressure. Bacll'li (sing. Bacillus). The most important group of
bacteria, so called from their resemblance to .small rods. Bacteria (singular. Bacterium). A general term for the
lowest form of vegetable micro-organisms which multiply by
fission. Bacteriol'og'y. The science which treats of bacteria. Conta'gium. Septic matter or germs of specific disease. Oul'ture. A term loosely applied to the product of the
propagation of germs in suitable fluids or other media. DiplococcuB, dip-16-kok'iis. Cocci united in pairs. Fermenta'tion. The process of decomposition due to the
action of living organisms or of an unorganized ferment. Frac'tional 8teriliza'tion. The process of sterilizing for a
fixed time on more than one occasion. Pis'sion. Reproduction by splitting into two or more equal
parts. Fomitee, fo'mite*. Substances capable of absorbing conu-
gious matter. Germ. The special virus or spore by which a disease becomes
communicable.
VOCAliVt.AfiY
5S3
Ger'niicide. An agent which destroys germs. Immu'nity. Freedom from risk of infection. Incuba'tion. The period which intervenes between the im- plantation of the virus and the appearance of the disease. Infec'tion. The process of communicating the germs which
produce a disease. Infec'tioua. Capable of infecting. Inocula'tion. The act of introducing a specific virus into
the system. Macroscop'icni. Visible to the naked eye. Me'dium. That in which anything lives. Mi'crobe. A micro-organism. Micrococ'ous- A spherical bacterium. Microscopical. Not visible to the naked eye. but only
through the microscope. Nu'olear. Pertaining to the nucleus.
Pasteuriza'tion. The name given to a special kind of treat- ment of u substance, t. g., milk, with a view to the destruc- tion of micrubic life in it, and thus preventing decomposition. Pathogenic. Having the property or power 10 cause disease. Phagocyte, f.ig'i>-sit. A cell possessing the property of ab- sorbing and digesting tMCtuil Phagocyto'sU*. Destruction of microbes by the action of
phagocytes. Putrefac'tion. Organic decomposition. Saprogenic, sap-ro-gen'ik. fin forming Spirillum. A genus of bai
Sporadic. Scattered ; occurring in isolated cases. Spore. The form of reproductive body in cryptogams analo- gous to the seed. Staphylococci (sing, -as), A class of microbes. Streptococ'ci (sing, -»>). Bacteria arranged in strings. Ther'moetat. Any automatic device for regulating tempera- ture. Wru*. A poison which cause? n morbid process or disease ; any pathogenic microb*
INDEX
Abbreviations. 235, 237.
Abdominal section, 304.
Abdominal section, cart af- ter. 406.
Abortion, 488,
Abscess, .1.1.1. 414.
Accumulative action of drug*, 230.
Acetic-acid and heat test for ■IburaiOi 274.
Acid, boric. 84.
■ .ItliollC. 8l.
nitiic, 273. oxalic. 85.
Actual 1 inlay, at*.
Acupressure. 360.
-i'liis, 151. After-pains. g Air. composition of, 61. Air-bed, 114. Air-cushion, 114. Albumen-water. 246. 435, Albumen, tests fur. -73-I
Albuminuria) 296.
in puerperal slate. 510.
in scarlet fever. . Alcohol, absolute. Alcohol. 248. Alcoholic Intoxication 305.
Amnion. 487. Amputations, 339-
111a. 301. Ana- ■■:' • -1.1, .(17.
preparation of patient for. 4f& hetics, 417-426. local. j-.-c.-6. 517. Anatomy, instruction in, jo.
Angina pectoris, 295. Anterior poliomyelitis. aeu»,
474- Antidotes, 310-313 AntiKptii jift J81. Anuria, 272. rVortk insufficiency, 294.
stenosis, 294. Apoplectic fit, 305. Apothcraiiet' measure. 236. Appcn.li. in-.. jOj. Applications, external, tCjt, Appi measures, 336.
Aqua ammonia. 209, Articular rheumatism, acute,
Artificial respiration, 307-8,
i Ascites. 284. Ami- ]8l.
Asiatic cholera. 440. Asphyxia of the new-born,
15'. 5«»- Aspirator. 314. Asthma, 285. Auscull wel, 314.
Autoclave. 8a
B
Bacillus. 317.
of tuberculosis. 265. 447. Bacteria. 76
ion by, 78,
I -"8. "5. 186. Bandaci
Bartholini's gland, cyit of, 41a.
sse
|
556 INDEX |
|
|
Bath for the new-born. 453. |
ten, .'h-.m:. |
|
Bath*, bed. ij& |
Blood, examination of. 301. |
|
bran-. 145. |
Blood-infection. 310. |
|
cJuaiSeatna of. 138 |
Boot . 39. |
|
for cleanlinc*». 130. |
Boric acid. X4, cj. |
|
14, 151-3 |
Bradford frame. 355 |
|
continuous, 154-5. 361. |
Bran-hags. 198. |
|
141. |
Brand's treatment. 151. |
|
air. 144, |
Brea«l*. care of the. 506-8. |
|
hot-vrater, 141. |
Breathing (see Respiration), case. 396. |
|
'. «45 |
|
|
mustard-. 141 |
|
|
physiological action of. |
Bronchitis. 364. |
|
'4--. 153. |
foe*, 330- |
|
salt-water, 145. |
Buck's extension apparatus. |
|
special. 147. |
354 |
|
Bponge, 148. |
Burns, 358. |
|
starch-, 145. |
classification of. 359 |
|
tub-, 131. |
treatment of, 359-361. |
|
vapor-, I4J. |
|
|
warm, 143. 474- |
C |
|
Bath-tubs, care of. 57. |
|
|
Bed. coverings for, 104. |
Cesarean section, 416. |
|
fracture. 109. |
Calculi, 33R |
|
making and changing. |
Cantharida! blister, 211. |
|
104. |
collodion, tti. |
|
mattress for, 103. |
Carbolic acid, 8t. |
|
for operation-patients. |
Carbolixed poultice, 197. |
|
108. |
Carcinoma of cervix uteri. |
|
Red-bath. 139. |
412 |
|
Bed-cradle, 1 16. |
Cerebrospinal meningitis. 391. |
|
Bedding, disinfection of, 95, |
Cardiac disease, 265, 293. |
|
Cataract, J 16. |
|
|
Bed-patients, appliances for, |
Catgut ligatures. 387-8. |
|
tII-18. |
Catheter, care of. 160, |
|
mm ing of, 116. |
Catheterization. 167. |
|
ide record. 101. |
Cautery. *'4. ^7 |
|
Bed 0(«l 113, 139- |
Cclloidin solution. 302. |
|
prevention of. 113, tao. |
Centigrade scale. 174. |
|
trcatmnt of, 1314 |
Cervical canal, stenosis of. |
|
Bedsteads. 101 1 |
411. |
|
Bichloride of mercury, 8t, |
Cervix uteri, amputation ot |
|
113 |
|
|
Bile in urine. 276. |
carcinoma of, 4>»- |
|
Bladder, irrigation of. too. |
laceration, of |ii rcoal poultice; 107. |
|
410 |
|
|
Blankets, care of. 57. |
darting tempcratiirea. 178, |
|
Bleeders, 37ft 180. |
/XDF.X
SSI
Chest-pack. I46. Chcync-Stokcs respiration.
t8o.
Children. nursing of. 45°-
482.
{ lull. 261.
<. lil.. ndc of lime. 84.
Chloroform. 423-5-
as a rubefacient, 309. Cholera, Asiatic. 440.
infantum, 471. Chore*. 475. Chronic diseases, 134. Cleanliness, surgical. 319. Clinical thermometer, 174-5- Clothes, care of path 123
Clothe* tan, 124-
Cocain. 435, 517. Cocliotomy, 414. Coffee as a stimulant. Cold, exhaustion from. 361. external applications .it. 301, 513. Colic, infantile. 465.
i-4S- Colles' fracture, 353. Colostrum, 506. Colpocelc. 413. Coma. 367, 306. Compresses. 300-3. Conception. 483. Constipation, in children,
in typhoid fever. 431. Conruaions, 3*0. Convalescence, care in, 133" Convalescents, food for, 348. Convulsions, in children. 473.
in pregnancy. 480, 510.
uremic. 37s. 396. Cough. 364.
Corrosive sublimate, 81, 83. Counter-irritants, 205-17, Course of training, outline
for, 17
preliminary, 18, 31. Crane. III.
I method. 403, Crinoline bandages. 345. Crisil 111 fevers, 170. (roion oil, 310. Croup, 476.
membranous, 443, 477- Croupous pneumonia, 385-8. Cupping. 310
Curriculum, subjects in. 18. Cushions. 118. Cyanosis. 304. Cystitis, 410. Cystocele. 413. Cystoma, 414.
Dead, care of the, 136. Delirium. 367.
tremens, 293. Dermoid cyst. 414. Diabetes, insipidus, 300. mcllitus. 390.
hea. 383. in children, 469, in typhoid fever, 431. Dicrotic pulse. 185. Diet. 338-353. Diet-kitchen, course in, 35,
340. Diphtheria. 443. 477. 1, care of, 343. lii hos for operating-room.
3B« Disinfectant solutions. 81 86. 88.
■•tarns. 8t. Disinfection, of hed-patis. 08 of bedding and cloihcs.
95. 9& of room. 94 of sputum. 07. 08. of sputum cups. 97. of stools. 1)6. of urine, 98.
Dislocations. 357. led water, 87.
Dorsal position tor gynaeco- logical patients. 40a
|
558 INDEX |
|
|
Dowse, rules for, 239. Douche, 165. |
method of giving. 157 nutritive. tWX |
|
aural. 519. |
purgative. 150, |
|
cold. 148. |
rashes resulting from. 164. |
|
vaginal, 165. |
rectal, 163. |
|
Drainage. 388. |
sedative. 164. |
|
Drainage tubes, .188-9. |
■simple. 1 57 |
|
Drev;Kiv;-...imu|tc, 337. |
stimulating, 163. |
|
Dressings, surgical, 380, |
turpentine, 165. |
|
Drip-sheet. 148. |
Emergencies, medical, 303. |
|
Dropsy. 384. 305. |
surgical, .W7. |
|
Drowning. 307. |
: ill's. 469. |
|
Drugs, accumulative action |
Enterocolitis. 47'- |
|
«f. 330. |
l.m.-rorrhagia. 379. |
|
idiosyncrasies for. 330. |
W4, 536. Fpileplic attack, 304 |
|
habit for. 330. |
|
|
toleration for, 330. |
Epistaxis, 374. |
|
Dry cups, 310. |
t. 501. |
|
Dry heat. 70, to.'. |
|
|
Dying, care of the, 135. |
Biher, idmbiistratloa of, |
|
Dysentery. 430. |
A*>-3- |
|
in children, 471. |
u-r-cone, 430. |
|
Dyspepsia, 381. |
Examination!, 2a |
|
Dyspnxa, 265. |
gynaecological! 40a Excreta, disposal of. 96-09. |
|
E |
Exhaustion, due to cold, j6l. |
|
Ear, affections of. 263, 518. |
due to heat, 306. |
|
care of. S'8-539. |
Eye. jtfj. |
|
foreign bodies in, 363. |
diseases of. 513 |
|
syringing of. 519, |
foreign bodies in, .<'>-• |
|
Ear-ache. 5 '9. |
symptoms referable to, tfj. 513. |
|
Ecchymosi*. 375. Eclampsia, 489, 510. Economics, household, 33-35. |
|
|
F |
|
|
of hospital ward, 43. |
Face, expression of. 359. |
|
Economy, importance of, 49. |
Fahrenheit scale, 174. |
|
Ectopic gestation. 415. |
Fainting fit. 303. |
|
Er/icma. 47.H, 5.-i. |
Feinting, following hemor- |
|
"•tricity. 533. |
rhage. 376. |
|
Emergencies, medical, 303. |
Frilling'* test for sugar 27* |
|
Empyema, 290. |
Fermentation test for sugar, |
|
Enaocardftii, 393. |
*74- |
|
1 nlnmetritis, 411. |
Fever. 17S. 437. |
|
Fn.-mata, 1561 |
continuous. 178. |
|
astringent, 164. classification of, 156. |
food in, 346. |
|
intermittent, 170. |
|
|
emollient, 164. |
malarial, 435. |
|
laxative, 158. 1 |
milk, 506. |
ISDEX
559
puerperal, 50B, remittent. 179. scarlet. 437. ipttted. 291. typhoid. 429 water in, J47- 434- Rinses light. 522.
year, work for, 18, at-
35- Fistula, 336. Flatulence, 266. tit, care of, 54.
. 486. lamentation*, 10R Food, adnin-i-ii.iiiiin of, 343. : c.-)iittitiicnti. ajj.
Foot-balli, I |l
Foreign bodies, in ear, 363.
in eye. 362
in IKWC; 36a.
in throat. 364. Formaldehyde, 85. 1-ractiire-bcd. 100. Fracture*. 340-357-
classification of. 35a
symptoms of. 340.
treatment of, 35'.
Case*, diffusion of, 66. Gastric ulcer, a8t.
'-utc. a8t. Gauze dressing. 380.
fi 1 vaginal pack*. 40a.
Gavage, 316. German measles, 480. Germicide*, Ki Germ*, pathogenic, 319.
Glaucoma, gtoi
Gmelius' test for bile. tj6.
Granular lid*. S15,
Granulation, jai.
Green-Mick fracture. .150
Gynaecological dressings,
preparations for. 404. exam prepara-
tion* for. 400.
operation*. preparation
for. 40+ patients. 30R. OWC after operation*.
406- to. care before operation,
399;
position*. 400-401. terms, 410-416.
H
Hematemeji*. 379. Harmatoma, 414. Hematosalpinx. 414. Hematuria, 278. ,)*J Hemoglobinuria, 278. Hemorrhage. Br, 366-379
antc-partum, 489.
arrest of, 368-37*
.. : J .- r > .1 1 . 367. .176
rlaanorrhagea, capillary, 378.
intestinal. JffQ.
in typhoid fever, 431.
post-parlum, 50a.
pulmonary, 378.
rccUl. 375.
spontaneous. 366.
symptoms of. 367.
syncope following;, 376.
traumatic, jfA 37--.
uterine, m, 409.
venous, 367. 377. Hemorrhagic diathesi*, 378.
'■rrhoids, 333. Hair, care of the. 126-7. Hand*, condition of, 263. Handkerchief bandage. 346. Head-rest, t U. Heart, diseate* of, 265, 393
Heat. 78.
dry. 79. I9».
exhaustion due to, 307.
external application of, 19a.
■Mat, 79. 194. aoo Heat-stroke. 306 Heat test for albumen. 274. Hccl-rcst, 114. 343'
|
560 INDEX |
|
|
Heller's test for albnmrn. |
Instruments, 38?. for gj narcological tires- |
|
-74- |
|
|
Hi miplctcia. 390. |
linn, preparation of, |
|
Hernia. 336. |
?"- |
|
Herpes roster. 521. |
Intermittent fever. 179. |
|
Hives, sji |
pulse. 184. |
|
Hop bag*. 198. Hospital ward, {iff Ward). |
Intubation, 335. |
|
hum, dons, 227. |
|
|
Hydrophobia, 300. |
Involution, 505. |
|
1 1 \ ir- Salpinx, 114 |
Iodine applications. 209. |
|
Hygiene, instruction in. 29. |
Iodoform celloidin, 392. |
|
nf lick room, 59. |
[bdoforaiad gauze, J9Q. |
|
personal. 73. |
glycerine, yji. |
|
Hypodermic medication, -■••-•. |
oil, 302. |
|
methods of givinK. 224. |
iriti'. 515. |
|
ncedlea for. 224. |
1 notation. 90. |
|
Hysterectomy. 415. |
J |
|
Hysteria, 525. |
|
|
HysteTO-niyomectomy. 415. |
Japanese hot-box. 519 Jaundice, infantile, 465, K Knee-chest position, 401. |
|
Hyjtcrorrhaphy, 415. |
|
|
I |
|
|
Ice-bag, 202. |
|
|
Ice-poultices, 203. |
L |
|
Iced compresses. 200. |
Labor, 490. conduct of, 497-5°3. |
|
[OC wnter coils, 203. |
|
|
Icterus, infantile. 465. |
duration of, 4'M- |
|
Idiosyncrasy for drugs, 23a |
prcniaturc, 488. |
|
Incompatibles, ajt. |
preparation for, 495. |
|
Incontinence of urine. 272, |
Lacerations of cervix, 411. |
|
279. 475- |
of perineum. 4II, |
|
Infant, bathinjr. 4S3- |
Laparotomy, 414. |
|
feeding, 45^463 |
Laryngitis, membranous. 477. |
|
Infantile paralysis, 474. |
Lateral position. 401. |
|
Infection of wound*, 318, |
1 H.IC.C i.f III .• 1 liT. -1IO. |
|
3«>. .W- |
of stomach, 31$- |
|
Infections diseases, 427-449. |
Lccchcs, 212. |
|
Inflammation, 32.V |
Library, reference, 39. |
|
Infusions, intravenous, 226, |
Ligature, 387-388 |
|
subcutaneous, .vj. |
1-iinc, chloride of, 84. |
|
Inhalations, 228. |
milk of. 83. |
|
Insane, care of the. 523. 5.7. |
Linen bonk. 50. |
|
1 inanity, puerperal. $11. |
for ig rooms, 383. |
|
IflSCCta in the car. 363. |
lists. 49. |
|
Insolation, .106. |
-room. 49. |
|
Insomnia, 527. |
1 iniments. |
|
in typhoid fever. 432. |
■ i poultice, i'>j. |
|
INDEX 561 |
|
|
Lochia, 505. |
-poultice, 206, |
|
law, 336. |
Myomectomy. 415. Myxedema, 296. |
|
L01 "motor ataxia, 200. |
|
|
Lotions, .204. |
|
|
1 ;, in fever, 179. |
N |
|
Nausea, 331. |
|
|
m |
Needles, hypodermic. 234. |
|
Malarial (ever, 435. Massage, 530. Materia medica, tastTrJCtlOfl in. 32 |
Nervous system, disease of, |
|
523. symptoms, referable to, |
|
|
Mattresses. 103, 114. |
Neuralgia, 292. |
|
care of 57. |
New-born, care of the, 451-6, |
|
Mcasle*. 479. |
Soo. 5»7- |
|
Mechanical appliance*, 354. |
patients. 121. |
|
Medical emergencies. 303. |
Nightingales. 133. |
|
Medicine chert, 233. |
Nipples, in' ol the, 506-8. |
|
Hats, 232. |
Nitric aeid teal for albunien. |
|
Medicines. 2t8. |
97* |
|
action of. 219-220. |
Non-infected wounds, 321. Normal salt solution, 3861 |
|
administration of. 219- |
|
|
223. 231. |
Nose, foreign bodies in, 362. |
|
in. ompatiblc, 331 |
Nurse's toilet basket, 51. |
|
Membranous croup. 443. 477. |
Nylandcr's te»t for sugar. |
|
Meningitis. 291. 474. |
275- |
|
Meningococcus intracdllula- |
0 |
|
ris. 291. |
|
|
Metric system, 88, |
Observation, habits of, 48. |
|
Metritis, 41" |
|.\i 512. |
|
Micro-organisms, 76. |
instruction in, 31. |
|
Micrococcus. 317 |
Oedema, 295 |
|
Milk diet, 246. |
liorectomjr, 415. |
|
of lime. 83. |
Operating-room, 3s"-397- |
|
modification of, 457-460. |
(operations, care after, 331, |
|
pasteurization "(. 462. |
395. 406. |
|
iterilitation of, 461. |
in private houses. 396. |
|
"Milk fever." 506. Mi-.-.uri.iRe. .!«& |
nourishment after. 408. |
|
prcptntna f"r. .i28-33i. |
|
|
Mitral-valve disease. 204. |
|
|
Monoplegia, 290. |
1 iphthalmis, 5'4-5'S. |
|
Mouth and teeth, care of, |
neomtoroBA 465. |
|
127. |
Order, importance of, 48. |
|
Mouth- sponges, 128. |
[l -rly. duties of. 58. |
|
Mouth-washes. 128. |
Orthopedics, 339. |
|
Mumps, 481. |
Ol uteri, stenosis of, 41 1. |
|
MuMard-batb. 141. |
Ovarian cystoma, 414. |
|
• leaves. 207. |
Ovariotomy. 415. |
|
-plaster, 206. |
Ovaritis. 414. |
|
^a^^^^^B |
|
|
562 INDEX |
|
|
Oxalic acid, 85. |
Polypi uterine, 412. |
|
■ iri.1. 276. |
Post-partcm Ii.rtini! r liaise. y>." |
|
Oxygen, inhalations of. 288. |
Potassium permanganate. 94. |
|
Pott's fracture. 35.1. |
|
|
P |
Poultices. ig«>8. |
|
Packs, 145. |
carbolized. 197. |
|
chest. 146. |
charcoal, 197. |
|
cold. 147. 150. |
ice. 203. |
|
vaginal. 4°3 |
jacket. 197. |
|
warm. 147. |
linseed. 195. |
|
Pads .mil cushions, 118. |
mustard. 198, 206. |
|
Pain. |
starch, tj |
|
P ilpil 'lion. 294. |
yeast. ro8. |
|
Paquelin cautery. 214-217. |
Pregnancy, 483. |
|
Paralysis. 290. |
changes during, 484. |
|
diphtheritic. .MS infantile. 474. |
diagnosis of. 484. |
|
duration of. 485. ectopic, 415. 41& |
|
|
Paraplegia. 290 |
|
|
Paresis. „"/>. |
rule for calculation of. |
|
Parotitis, 481. |
485. |
|
Parovarian cyst. 415. Patients, care of new, tat. |
symptoms of. 485. tubal, 4161 |
|
Per cent. use of tenn, 93. |
Preliminary course. 18. 21. |
|
Pericarditis, 293. |
Premature labor, 488 |
|
Perineorrhaphy, 412. |
Prescription-, 234. |
|
care of patients after. 408. haemorrhage following, |
Pressure in arrest of haemor- |
|
rhage. 369. |
|
|
40u. |
Probationers. 53. |
|
Perineum, lacerations of. -jr.- |
Puerperal fever. 508. |
|
Peritonitis, 283 |
insanity, 511. |
|
Permanganate gauze, 390. |
1'"' rperium. 504-6. |
|
Pertussis. 4S1. |
Pulse. 18a |
|
404. |
dicrotic. 185. |
|
Pharmacy, instruction in. .13. |
tension of. 185 |
|
Phlebitis, septic, 509. |
types of. 184. 185. |
|
Physiology, instruction in, JO. |
Pyxmia, 325. Pyelitis. 278. |
|
Pills, administration of. 221. |
|
|
Placenta. 489. |
Pyoialpinx, 414. |
|
care of. 501. |
|
|
delivery of, 402. |
Q |
|
pr.-rvi.-i. 489. Plaster of paris bandages. |
Quarantine, 99, |
|
34*. 344- |
R |
|
Plasters, 206-208. |
|
|
Pleurisy. 28ft |
Rachitis. 476. |
|
purulent. 290. |
Reference library, 39. |
|
Pneumonia, 285. |
Reaumur scale, 174. Records, keeping of, 191, 268. • |
|
Poisons. 233, 310313. ft |
INDEX
563
lectal medication, 163. Rectal lube 167. Rectocele, 413- Rectum, packing the. 375. Refrigerator, care of, 242. Relaxed vaginal outlet. 411. Remittent fever, 179 Report, form of, 41.
Hi'". 187.
character of. t88. ne-Stokca. 180.
stertorous, 189, Rest-cure, 529.
Rctentic-a of urine. 272. 278. Rheumatism, 298, Rickets. 476. Ringworm, 521. Roentgen Rays, 364-5.
Round*, ineilir.il, 316. ■:'-M I, 3*7-
Rubefacients. 205, Rubella. 480. Rubeola. 479-
Salpingitis, 4:4.
Salpingo-oophorectomy. 415.
Salt -bag*. 194.
Salt bath. 145
Salt solution, normal. 386.
Saprxmia. 325.
Scalds, 3S8.
Scarlet fever. 437-440.
Sciatica. 292. y
Scultetu* bandage. 405
Second year, work for. 19, 35-
37- Septicaemia. 325. Shingles, UI. Shock m& Silk ligatures. 387. Silkiv 388.
Silver f--.il. 380. Silver wire. 388. Sim's position. 401. Sinapisms. 207 263. disease* of, $2o-5«
Skin-grafting 361.
Sleep. 261. 527.
Small-pox, 441.
Solutions, preparation of. 90-
94 Speculum, Suns', 401. Spice-plaster, 208. Splints. 354. Sponge-bath. 148. Sponges, 390-1. Mouth-. ta&
- .t5& Sprue. 467. Sputum, cue of. 97, 98. Sputum in tuberculosis, 265.
"pinlir juice." 286.
-cups, 97. f)6. 449
St.lphyliiCiM-i-us, 317.
Starch-hath, 145.
-encmata, 164. poultices, 197. Stenosis of o« uteri, 411. SterilintJon, 7S
of dressings, 389.
of ils, 38s.
of ligatures. 3X7.
of milk. 461.
of solution*. 386. Sterilizers. S&4 Stertorous breathing, 189, Strabismus, 51ft Streptococci!*. 318, 324. Stretcher, 131. Stupes, too. Stupe-wringer, 190. Si. Villi*' dance, 475. Subcutaneous medication, xaa Subinvolution. 505. Sugar in urine, tests for. 274-
Sunstroke. 306. Suppositories. 227. Supprc-nn of iimiic, 272. Surgii'.il .!ii --uig«. ,189 emergencies. 347
itfog-room, 380-JP7.
care of. 382. linen-lUt for. 383.
|
564 INDEX |
|
|
round*, 327.- |
first-year work for, tg, |
|
# te >8o. |
preliminary course in. iR |
|
Saspensio uteri, 415. |
|
|
Suture materials, |
ji |
|
Symptoms. ob«ervation of. |
second-year work for. to. |
|
353-369. |
35.17 |
|
Syncope, .503. |
third-year work for. 19, |
|
Syringing the car, 519. |
.17 J8. |
|
rreatment, record of. 189. |
|
|
T |
Triturates, -•-•.' |
|
Tabes, ago. |
Trommcr's test, 274. |
|
Tampon*. 403. |
Tubbiog, 151. |
|
Taste, symptom* referable to. |
'i ubereulosis, 265, 4461 |
|
-•OR |
|
|
Tea a* a stimulant. 248. |
eneraata, 165. |
|
Teeth, care of patients', 1.7. Temperature of body, 171. |
stupes, 268, 43a. |
|
Tympanites 432. |
|
|
model of taking, 175 |
Typhoid fever. 420-435. |
|
Temperature, 171. |
consti 431. |
|
abnormal, 173 |
diarrhrca in, 431, |
|
charting of, 170. 180. |
dirt in. 433. |
|
"paradoxical", 178. |
bamorrh&ge in, 43a. |
|
Tent, moist-air, 300. |
Insomnia |
|
Tetanu*. 326. |
I*"' '". 4.U. |
|
Text-books, 39. |
432. |
|
Thermic fever. 306. |
tympanites, 432. |
|
Thermometer, clinical. 174. |
|
|
Third year, work for, to. 37. 38. Three-years course, outline |
u |
|
Ulcer, gastric, a8t. |
|
|
for. 17. |
Ulcers, ssi |
|
Throat, diseases of, 280. 51R |
Umbilical cord, 409, 500, |
|
for. ■■■■ |
bleeding from, |
|
obstruction in, 115. \<n |
«* |
|
Thrastt 467. |
I prighl position for gynieco- |
|
'in douloureux, 292. |
logical patients, 401. |
|
Toilet basket 51. |
Uraemia. 278, |
|
Tongue, condition of, 262. |
Urates, 276. |
|
ilitis, 280. |
icid. 376. |
|
Tourniquet, 373. |
Urine. 370-279. |
|
Trachcorrhaphy, 411, |
albumin in, 273. 396, |
|
Tracheotomy. 334. |
color of. 272. |
|
Trachoma, 515 |
km of, 98 |
|
Training-school. 17. honks fur. ,v, |
incontinence of, 373, 379. pus m. 97a |
|
ciirrifiiluiii for: |R |
|
|
division of time in, rR |
reaction of. 371. |
|
examination- |
retention of, 372, 378. |
INDEX
5*5
sediments in, 273. 27s,
276. specific gravity of, 271,
272-3. specimens of, 277. suppression of, 272. Urticaria, 521.
Uterine hemorrhage, 37s, 409.
Vaginal douche, 165.
examinations, 400.
during labor, 497.
hysterectomy, 415.
outlet, relaxed. 411.
packs, 402. Vapor-bath, 143. Vapors. 228. Variola, 441. Vesication, 205. Venesection, 315. Venous haemorrhage, 367,377. Ventilation, 61-70.
instruction in, 29. Vomitus, 266.
•w
Wafers, 221. *
Ward, arrangement of, 43-
cleaning of, 55-58.
daily care of, 52.
floors in. 54.
furnishings of, 43-46.
hygiene of, 59.
linen-book for, 50.
private, 44.
public, 43.
rounds in, S3, 316, 327.
supplies for, 50, 51.
surgical, 43.
utensils in. 57.
weekly care of, 56. Water-bed, 114. Water, distilled, 386. Wet cups, 210. Whooping-cough, 481. Wound infection, 318, 320,
321. Wounds, aseptic. 321.
classification of, 320.
healing of, 320-323.
infected, 320, 321.
pon-infected, 321.
c*jr -'-*"
|
IT41 Robb. lira. I. B68 Nursing. 7C119 1909 |
|
|
NAME |
Mil |
|
^B |